RUSSELL SAGE 
FOUNDATION 



MEDICAL INSPEC- 
TION OF SCHOOLS 

By LUTHER HALSEY GULICK.M. D. 

DIRECTOR OF PHYSICAL TRAINING, NEW YORK 

PUBLIC SCHOOLS 

AND 

LEONARD P. AYRES 

GENERAL SUPERINTENDENT OF 
SCHOOLS OF PORTO RICO, I906-I908 



NEW YORK 

CHARITIES PUBLICATION 

COMMITTEE 

MCMVIII 



L ,T^ 



LIBaARV of CONGRESS 
Tv Copies Received 

OCT 27 1908 

Copyria.'u Entry 

CLASS Ol, XXc. No 

COPY 3, 



Copyright, 1908, by 
The Russell Sage Foundation 



PRESS or 

WM. r. FELL COMPANY 

PHILADELPHIA 



Contents 



Introduction 

PAGE 



Significant Facts 



CHAPTER I 

Nature and Aims of Medical Inspection 

Protection of the community S 

Development of the individual 5 

Our change from rural to urban life . " 

Population of foreign parentage in American cities 7 

Changed conditions of work ° 

Changed conditions of play 9 

CHAPTER II 

The Argument for Medical Inspection 

The attitude of educators towards the physical well-being of children . .12 

The "lockstep" in physical matters ^3 

Awakening interest in problems of backward children 14 

Physical defects and school life ^5 

Medical inspection does not entail trespass on personalliberty . . . .16. 

CHAPTER III 

Historical 

Rise of medical inspection in France 1° 

Rise of medical inspection in Belgium and Germany 19 

The Wiesbaden plan ^9 

Hungary, Austria, and Norway 20 

Sweden, Roumania, Moscow, and Switzerland 21 

The English Medical Inspection Act 21 

La Medecine Scolaire ... 22 

Chile, Argentine Republic, and Japan 23 

New York City 24 

State Laws of Connecticut, New Jersey, Vermont, and Massachusetts . . 25 

Cities of the United States having medical inspection 26 

CHAPTER IV 
Inspection for Detection of Contagious Diseases 

Exclusion cards ^9 

Medical inspection in New York City 3° 

iii 



iv Contents 

PAGE 

Forms used in Providence, R. 1 40 

A system of records for medical inspectors r 41 

Combined directions and prescriptions 46 

Contagious diseases for which pupils are excluded 48 

Beneficial results of medical inspection 50 

CHAPTER V 

The Work of the Teacher in Detecting Contagious Diseases 

Competence of teacher to detect symptoms of disease 52 

Directions for referring pupils to school physician ••>.•• 55 

Hygiene rules for pupils 57 

Forms used by teacher to refer pupils to school physician . . . . -59 

CHAPTER VI 

The School Nurse 

Opinions on the value of school nurses 66 

The w^ork of school nurses in New York City 67 

The work of school nurses in Philadelphia . 69 

The work of school nurses in Boston 73 

Forms used in connection with work of nurses 77 

CHAPTER VII 

Physical Examinations for the Detection of Non-Contagious Defects 

The basis of the argument for conducting physical examinations ... 82 

Results of vision and hearing tests in public schools 83 

Physical examinations in New York City 86 

Application of work of school physician to work of class room .... 89 

Forms used in connection with physical examinations 94 

Directions concerning the care of the teeth . . .98 

Extent to which defects discovered are remedied loi 

CHAPTER VIII 

Vision and Hearing Tests by Teachers 

Ability of teachers to conduct vision and hearing tests 104 

Sight and hearing tests in Massachusetts 107 

Eye and ear examinations by New York State Department of Health . -113 
Eyesight tests conducted by State Board of Education of Connecticut . . 120 
Examinations of the State Board of Health of Utah 129 

CHAPTER IX 

Administration 

Four classes of systems of medical inspection 137 

Salaries of medical inspectors and number of pupils per inspector. . . -139 

Salaries of school physicians in England 142 

Salaries of nurses i44 

Salaries of medical inspectors in Germany 144 

The question of free eyeglasses 148 



Contents v 

CHAPTER X 

Controlling Authorities 

PAGE 

Board of Health or Board of Education 15° 

Detection of contagious disease a function of the Board of Health . . . 158 
Development of the individual a problem for the Board of Education . . 158 

CHAPTER XI 

Legal Aspects of Medical Inspection 

The English law . ^59 

The Massachusetts act ^^^ 

The New York law concerning children in public institutions . . . .166 

The New Jersey statute ^7^ 

The Connecticut law ^7^ 

The Vermont law ^^^ 

CHAPTER XII 

Retardation and Physical Defects 

Medical inspection and financial economies 185 

Retardation and part time ^^^ 

Class standing of children and physical defects 189 

Causes of backwardness ^9° 

Physical defects and age in grade 192 

Decrease of defects with age ^99 

BIBILIOGRAPHY 

APPENDIX I 

"Suggestions to Teachers and School Physicians regarding Medical Inspec- 
tion," issued by the Massachusetts Board of Education ... .222 

APPENDIX II 

A typical set of European blanks and forms (those used in Briinn, Austria) . 238 

APPENDIX III 

Rules issued to medical inspectors of schools in Chicago, 111. ; Detroit, Mich. ; 

and Springfield, Mass 251 

INDEX 



vi Contents 



Charts 

PAGE 

1. Teeth chart, Northampton, Mass 97 

2. Snellen's chart for testing eyesight, Massachusetts iii 

3. Chart of letters for testing eyesight, Connecticut 122 

4. Chart for testing focusing power, Connecticut 123 

5. Chart of graduated figures, Connecticut 124 

6. Chart of E's, Connecticut 125 



Forms 

PAGE 

1. Exclusion card, Brockton, Mass 30 

2. Monthly report of medical inspector, Brockton, Mass 31 

3. Postal card notice to principal. New York City 34 

4. Exclusion card. New York City 35 

5. Code card. New York Cit}^ 36 

6. Index card. New York City 37 

7. Inspector's daily report of exclusions, New York City 38 

8. Inspector's daily report of exclusions; reverse; New York City ... 39 

9. Exclusion notice, Chicago 42 

10. Envelope daily report of medical inspection, Chicago 43 

11. Combined directions and prescription, Everett, Mass 44 

12. Combined directions and prescription, Everett, Mass 45 

13. Rules for contagious diseases. Providence, R. 1 56 

14. Printed rules distributed to pupils, Providence, R. 1 57 

15. Teacher's request to inspector, Providence, R. 1 59 

16. Card of request to inspector, Asbury Park, N. J 59 

17. Request of teacher and statement by inspector, Washington, D. C. . .60 

18. Duplicate of above 61 

19. Statements of physician and teacher, Somerville, Mass 62 

20. Card used by Dr. Newmayer in Philadelphia 63 

21. Slip taken by pupils to inspector, Philadelphia 64 

22. Card recommending pupil for treatment, Philadelphia 77 

23. Weekly report of nurse, Philadelphia 78 

24. Weekly report of nurse, Baltimore 79 

25. Individual record card, New York City 84 

26. Postal card notice to parents, New York City 86 

27. Reverse of above card . . .86 

28. Record card showing teacher's comments, Pasadena, Cal 90 

29. Reverse of above card 91 

30. Physical record card, Los Angeles, Cal 92 

31. Reverse of above card 93 

32. Physical record card, Utica, N. Y 94 

33. Physical record card, Asbury Park, N. J. 95 

34. Notification to parents, Somerville, Mass. . 96 

35. Notification to parents, Ann Arbor, Mich 96 

36. Report on eyesight and hearing tests to superintendent, Massachusetts . no 

37. Record of sight and hearing tests, Massachusetts 112 

38. Notice to parents or guardian by teacher, Massachusetts . . . -113 

39. Notice to parents or guardian by school physician, Massachusetts . -113 

40. Report of teacher, New York State 118 



Contents vii 

PAGE 

41. Report of teacher, New York State 119 

42. Notice to parents, New York State 120 

43. Teacher's report to parent or guardian, Connecticut 127 

44. Teacher's report to State Board of Education of Connecticut . . .128 

45. Report to State Board of Education of Connecticut 128 

46. Card of warning to parents, Utah 130 

47. Report by teacher, tltah 131 

48. Report to State Board of Health, Utah 132 

49. Teacher's report to principal, Ogden, Utah 133 

50. Blank for excuse for absence, Ogden, Utah 134 

APPENDIX II 

(Forms used in Briinn, Austria.) 

51. Notice to parents 238 

52. Notice to parents 239 

53. Health report 240 

54. Reverse of above report 241 

55. Monthly and yearly report of findings 242 

56. Monthly and yearly report of visits by school physicians .... 243 

57. Physician's report 244 

58. Memorandum blank of unhygienic conditions in school-houses . . . 244 

59. Questions to parents or guardians 245 

60. Individual health report 246 

61. Reverse of above form 247 

62. Notice to parents, dental 248 

63. Reverse of above form 349 

64. Notice to dentist 250 



Tables 



PAGE 



1. Table showing population of foreign parentage in various American cities 7 

2. Table showing cities of the United States having some form of medical 

inspection 26 

3. Contagious diseases for which pupils are excluded in five cities . . .48 

4. Examinations and exclusions in five cities 49 

5. Diseases and defects reported in Massachusetts 49 

6. Exclusions in New York City public schools 68 

7. Excludable diseases in New York City 68 

8. Table showing work of trained nurses, Philadelphia 70 

9. Table showing nurse's visits to homes, Philadelphia 71 

10. Table showing results of vision and hearing tests 83 

11. Physical examinations in New York City and Minneapolis . . . .87 

12. Facts in regard to medical inspection in 17 cities 140 

13. Expense of medical inspection, Springfield, Massachusetts .... 146 

14. Expense of medical inspection, Montclair, New Jersey 146 

15. Expense of medical inspection. East Sussex, England 147 

16. Standing in studies of normal and defective children, Philadelphia . . 189 

17. Defective children rated "exempt" and "non-exempt" in Philadelphia . 189 

18. Bright and dull children having nose and throat defects, Philadelphia . 189 

19. School standing of children having normal, fair, and bad vision, Phila- 

delphia 190 



viii Contents 

PAGE 

20. Reasons for excessive age of children, Camden, N. J 191 

21. Distribution of pupils by grades and defects. New York City . . . 192 

22. Distribution of pupils by ages and defects, New York City .... 193 

23. Physically defective pupils by grades and groups, New York City . . 193 

24. Average number of defects per child. New York City 194 

25. Per cent, having each defect. New York City 195 

26. Per cent, having each defect by ages, New York City 195 

27. Per cent, defective by defects and grades. New York City .... 197 

28. Defects per 100 children by grades. New York City 197 

29. Defects per 100 children by ages. New York City 198 

30. Per cent, having each defect by sexes. New York City 199 

31. Defects per child by sexes, New York City 199 



Introduction 



This volume is one of the by-products of the " Backward Children 
Investigation", a research supported by the Russell Sage Foundation 
for the purpose of studying so-called "retardation" among school 
children. The investigation was inaugurated in November, 1907. 
No small part of the study of the adaptability of the school and its 
grades to children has consisted of investigation into the effect of school 
life on the physical welfare of the child. In the course of this investiga- 
tion it has been found necessary to accumulate information as to what 
was being done for the health of children, from both the pedagogical 
and medical standpoints, in the chief cities and countries of the world. 
The information relative to medical inspection was so scattered, and the 
desire for reliable information on the topic so general, that it was decided 
that it would be wise to publish the available matter at once. 

This book aims primarily at results of a practical nature. We believe 
that it contains material of scientific value, but the form of presentation 
is intended to render it of service to all who are directly connected with, 
or interested in, the betterment and safeguarding of the health and 
vitality of the future citizens of America. 

The importance of steps looking toward the health of our public 
school children is indicated by the following facts: 

1. The school is the only governmental department that directly 
assumes control of children's lives. 

2. At least nine out of every ten of all American children are subject 
to this control; and 

3. Such control is maintained (roughly speaking) during the critical 
years of from seven to fourteen. 

Because of the practical nature of our objects, there have been 
included in the bibliography titles of books, reports, and articles on 



X Introduction 

medical inspection, containing material not relevant, and hence not 
used or referred to, in our particular study. 

There seems to be a general impression in America that medical 
inspection is still experimental and on trial, and that we are leading 
in this important work. The reverse of both of these impressions is 
true. With Brussels having a systematic inspection since 1874 and 
Paris since 1884, scientific journals in France and Germany devoted 
exclusively to this subject, and the movement a national one in France, 
England, Belgium, Sweden, Switzerland, Bulgaria, Japan, and the 
Argentine Republic, it is evident that, save in details, the matter is a 
settled one, and that America is one of the last of the civilized nations 
to seriously consider these problems. 

This book aims, then, 

1. To be of practical use. 

2. To be a reliable source of information as to what is now 

being done and how it is being done. 

3. To be frank in its admission of problems and difficulties 

not yet solved, as well as in the portrayal of stubborn and 
hitherto unsuspected and apparently unreconcilable facts, 
such as are discussed in Chapter XII. 

4. To avoid all dogmatism saving that involved in the statement 

of actual experience. 

L. H. G. 
L. P. A. 
New York, September, 1908 



Significant Facts 



Medical Inspection "is founded on a recognition of the close connec- 
tion which exists between the physical and mental condition of the child- 
ren and the whole process of education." It " seeks to secure ultimately 
for every child, normal or defective, conditions of life compatible with 
that full and effective development of its organic functions, its special 
senses, and its mental powers, which constitute a true education." — {Ex- 
tract from Memorandum of British Board of Education.) 

Medical Inspection is a movement national in scope in England, 
France, Belgium, Sweden, Switzerland, Bulgaria, Japan, the Argentine 
Republic, and practically so in Germany. In the United States seventy 
cities outside of Massachusetts, and all the cities and towns of that state, 
have systems of medical inspection. 

Massachusetts has a compulsory medical inspection law. New 
Jersey has a permissive one, Vermont a law requiring the annual testing 
of the vision and hearing of all school children, and Connecticut one 
providing for such tests triennially. 

As a rule, the work of medical inspection is underpaid in America. 
In England such services are compensated at the rate of from $1500 to 
$4000 per annum, while in America $200 has, in many quarters, come 
to be regarded as a standard salary for the services of the school phy- 
sician. 

Systems themselves vary so widely in scope and thoroughness here 
in America as to range in annual per capita cost from half a cent to a 
dollar and twenty-two cents. 



2 Medical Inspection of Schools 

Clear distinction must be made between medical inspection solely 
for the detection of communicable disease and that physical examination 
which aims to discover defects, diseases, and physical condition. The 
one relates primarily to the immediate protection of the community, 
while the other looks to securing and maintaining the health and vitality 
of the individual. 

Medical inspection for the detection of contagious diseases can be 
adequately performed at an annual cost of about fifteen cents per capita, 
while physical examinations similarly performed, and including the in- 
spection for the detection of communicable diseases, cost about fifty 
cents. 

Effective medical inspection for the detection of communicable 
diseases can only be conducted by the Department of Health, or at least 
with its active co-operation, because of the necessity for legal authority 
for protecting the community, not only during epidemics of contagious 
diseases, but also to prevent them. 

Effective physical examination can only be conducted by the Board 
of Education, or at least with its full co-operation, because it involves the 
following of the child from grade to grade and year to year. It involves 
the constant attention of the teacher with reference to seating the deaf 
where they can hear best, and those having poor vision where they can. 
see best, as well as constant co-operation with the parents. 

Physical examinations can be well made by an experienced school 
physician in from twelve to fifteen minutes per child. Vision and hear- 
ing tests demand from three to five minutes per child. 

The conduct of medical inspection is such a technical matter and is 
so different from the work done by the practising physician as to demand 
special training and experience. 

Investigations so far indicate clearly that physical defects of children 
decrease with age. That is, taking into consideration a sufficiently 
large number of cases, children of fourteen years of age show fewer de- 
fects than do those of thirteen years, and these, in turn, fewer than those 



Significant Facts 3 

of twelve years. Hence older children have fewer defects in whatever 
grades they may be found, and so, from the very definition of the term, 
retarded children in any given grade have fewer defects than children 
of normal age in the same grade. This fact is in direct contradiction 
not only to the prevailing opinion, but also to the conclusions that have 
been emphasized in current professional discussion to the effect that 
children behind their grades were so because of the handicap imposed 
on them by physical defects. This important fact should not in any 
way lessen our endeavors to bring the aid of medical science to the ser- 
vice of the physically handicapped. It should rather give us renewed 
hope, for we find that the direct tendencies of normal growth make to- 
ward rather than away from those wholesome physical conditions that 
it is the aim of every physician and every educator to bring about. 

Physical defects are not equally significant either from the medical 
or from the pedagogical standpoint. It is unfair and tends toward mis- 
leading conclusions to include in the same classification pediculosis and 
defective vision, club-foot and defective hearing, adenoids and ring 
worm. Therefore the effects of each kind of defect should be separately 
studied — e. g., the effects of defective vision, hearing, adenoids, carious 
teeth, etc., upon school progress and upon health. 



CHAPTER I 

Nature and Aims of Medical Inspection 

Two great forces have been making in America toward medical 
inspection of schools; forces that have hitherto been mutually uncon- 
scious and wholly unrelated as to source, objects and methods. It 
seems inevitable that the aims and objects of medical inspection are 
only to be accomplished by the coalescing of these two forces — each 
contributing what the other has lacked. 

On the one hand is medical science operating to protect the com- 
munity through its boards of health, while on the other is educational 
science operating through the great school systems of the world and 
expressing itself through its more or less scientific departments of physical 
training. Speaking historically, medicine has labored to cure and at 
best prevent disease and deformity, while education has aimed at the 
intellectual equipment of the individual. Pathology is prominent 
in the one case and development in the other. 

That community protection has been a chief aim from the medical 
viewpoint is indicated by the facts that 

(i) The detection of contagious disease has been uniformly the 
obvious and initial activity, and 

(2) That the records are almost, if not entirely, those of disease or 
deformity. 

That growth has been the chief aim from the educational standpoint 
is shown by the facts that where this work has had any scientific basis, 

(i) Exercise, cleanliness, ventilation, the importance of suitable 
and adequate nutrition, sleep, etc., have been primary objects; and 

(2) Records of height, weight, chest, girth, etc., have constituted 
the primary elements recorded. 

The distinction between these two forces is a philosophic one. It 
would not be true, for example, that hygienic knowledge has been 
absent on the one hand or medical knowledge on the other. The best 

5 



6 Medical Inspection of Schools 

medical inspection has included matters of personal hygiene and the best 
physical training has been directed by those having medical equipment. 

Dr. John J. Cronin, of New York City, has made most wise, ex- 
tensive, able and best known medical inspection from the standpoint 
of education, acting as an agent of the Department of Health, while 
George W. Ehler, of Cleveland, has put into operation a most effective 
educational program from the standpoint of medicine. 

It is to the departments of physical training in our colleges and 
secondary schools that we have to look in the main for our most com- 
plete records of growth and development. Still the classic and monu- 
mental work of Bowditch in measuring and weighing Boston public 
school children, as well as the work of Porter in St. Louis, and Boas 
in Toronto and Worcester, must not be forgotten. 

The forces that are compelling these two movements to coalesce 
consist in certain changes in the constitution of society which must 
now be sketched briefly. These changes must be examined from 
two points of view : 

(i) From that of the welfare of the community as such. 

(2) From that of the personal activities and functions, both physio- 
logical and social, of the individual. 

Let us take first the changes affecting the welfare of the community 
as such, involving an enlarged conception of the duties and powers 
of the Department of Health. 

We have to go back in our American history but a trifle over a 
century to discover that we were a set of rural communities — the urban 
population (cities of 8000 and over) at that time constituting but 3.3 
per cent, of the total population. Now we are an urban nation; 33 
per cent, live in cities. This percentage includes wide territories and 
vast sections that were not at that time a part of our country. When 
we examine the progress of the older and more advanced states, the 
direction in which we are moving becomes still more evident. New 
York has an urban population of 72 per cent.; Massachusetts 91 per 
cent.; Ohio 48 per cent.; Illinois 54 per cent., while Rhode Island has 
95 per cent. This moving of the population toward centers has rendered 
essential attention by the communities to the cleanliness of water supply, 
to sewerage, street cleaning, problems of Hght and air in dwellings, 
the isolation of cases of contagious diseases, the transportation of food 



Nature and Aims of Medical Inspection 7 

and hence its preservation and guarantee of its purity, conditions and 
hours of labor and a thousand other matters which in a rural community 
were of importance to individual families only. 

Of great importance also is the change that has taken and is taking 
place in our racial stock. This is important because standards of living, 
of cleanliness, of freedom from vermin, are being brought in by recent 
immigrants which are not only different from those that obtained under 
early American conditions, but which are inimical to those higher 
standards of life that are essential to the individuals in a democracy 
that is to endure. That this is a real and large factor is shown by the 
following figures taken from the last census: 

Per Cent, of 
(3i^Y_ Foreign Parentage. 

Boston 71-6 

Chicago 77-2 

Cleveland 75-4 

Milwaukee 82.7 

New York 76-6 

San Francisco 7°-4 

It is true that the percentage of foreigners in these cities does not 
represent that in the country at large. But these are among our largest 
and most important American centers, and the traditions that uUimately 
establish themselves in these cities are altogether more important to 
the country at large than would be indicated by the mere percentage 
of the total population that these cities contain. 

Our school systems have developed enormously during this period 
—developed altogether faster than has the population. What schools 
there were, were widely separated, were carried on for but a small 
fraction of the year, and were attended by but an inconsiderable fraction 
of the children. That is, the schools as such did not present any special 
problem from the standpoint of community hygiene. Now the school 
year lasts for ten months, and in many cities vacation schools round out 
the calendar year. So the schools in their intimate commingling of 
children from practically all families for most, if not all of the year, 
afford by far the most extensive means for the spread of contagious 
diseases that exist. 

Thus the community through its health boards has been forced 
not only to protect itself from the spread of disease in many ways quite 



8 Medical Inspection of Schools 

unnecessary in the earlier period, but has had to become (unconsciously 
even to itself) an agency for the establishment of American ideals. 
Boards of health have been compelled to lay forcible hands upon the 
school, time and again during epidemics, long before it became recog- 
nized that the school was permanently to be a possible focus and distri- 
butor of disease, and hence needed permanent and thorough medical 
inspection. 

Let us turn now to a consideration of those changes in the constitu- 
tion of society which have involved a readjustment of the physiological 
functions of the individual in his relation to the social organism. 

In the earlier period, and indeed during all of that portion of man's 
history which preceded the last century, the bulk of the world's work 
was done by human muscle. It is true that man has made great use 
of the horse, camel and a few other animals, that windmills and water 
wheels and sails have long performed incidental service; but the general 
fact remains that human muscles have built the pyramids, dug the 
canals, erected the houses, tilled the fields, gathered the harvests, made 
the cloth, fought the battles, carried the water, hewn the wood, as well 
as written the books for mankind. It is to be remembered in this connec- 
tion that it has not been a small fraction of the people that have been 
chiefly concerned in this muscular labor, but that most of the people 
have been so engaged for most of their years. We must not forget 
that even during the golden age of Greece — the age of Pericles — eight 
out of every ten of the people were slaves who labored. 

These conditions have changed. This is not a matter that concerns 
itself with the city as contrasted with the country, and hence is to be 
cured by reverting to country life. It has changed for most of the people 
for most of the years of their lives. 

It is not only in the city that one turns on the gas instead of chopping 
the kindHngs. The bulk of the world's work is done, not by human 
or even animal muscle, and not by vagrant winds. Man has harnessed 
the great powers of nature. He breaks his land with the gang plow, 
illuminates his night world with electricity, carries himself and his 
goods with elevators, automobiles, steam vessels, raihoad trains, sub- 
marines and in this century with flying machines. He no longer sows 
or reaps by hand; he makes his cloth and clothing, shoes, hats and 
even decorations by machines. 



Nature and Aims of Medical Inspection g 

This change is important most of all to children, for it involves 
the two chief agencies that have been responsible for their development 
into adults having strong vitality and clean morals. I refer to work and 
to play. 

The horrors of child labor are still with us, although sure to disap- 
pear, but the normal work with the parents, about and for the home 
has gone or is going. 

The all-round farm where a boy learned the rudiments of a dozen 
trades has been displaced by the specialized farm. The girls can no 
longer work with their mothers in carding the wool, making the gar- 
ments, managing the dairy or poultry. The small garden is disappear- 
ing save as a luxury, washing is better and more cheaply done outside 
the home, most of the cooking and "putting up" is done elsewhere. 

It is perhaps unnecessary to further illustrate the fact that that 
element through which the children have come into and partaken of 
the family labor, and so gradually have learned to carry on the world's 
work, has gone or is going. But — of even greater importance from the 
standpoint of this present discussion — that muscular work which 
strengthened the muscles, enlarged the chest, and aided in giving the 
power to live is largely gone. 

The other great source of muscular exercise and physical develop- 
ment which has been the heritage of all of the children of all of the 
world is play. This is being attacked from three sources, namely 

Time for play 
Space for play 
Traditions for play. 

School life has increased to cover six hours a day for ten months 
a year. The school has pressed its importance till "home work" 
takes from one to four hours of the rest of the day. Our children are 
busy most of the time. There is little time left for quiet play with dolls, 
wandering through the woods, or corresponding activities in which un- 
conscious growth occurs. 

We are already an urban country and are rapidly becoming more so. 
Not one city has been planned with the real object of human life in mind, 
that is, the rearing of healthy, happy children. Every other crop has 
been provided for but this one, and yet this one transcends them all 



10 Medical Inspection of Schools 

even in financial value. Our cities are being built up without play- 
grounds. Millions and millions have been spent on the Island of Man- 
hattan to remedy this lack of forethought, but allowing a scant space 
of three yards square for each child, only one child in ten can be given 
play room south of Fourteenth Street in this city. This is one of the 
reasons for the prevalence of such games as craps. It takes but little 
space, is quiet, can be played with a varying number of players, is 
interesting, etc. In fact, it is an ideal game for city children, with a 
single reservation. It is bad for their morals and useless as a developer 
of muscle or physical stamina. 

The great games of the world that have been handed down from child 
to child for hundreds or even thousands of generations, preserved 
in the amber of child tradition, do not in the main suit modern city 
conditions. 

Children do not bring their play traditions with them. It would 
seem as if a dozen families from a dozen lands would form a little com- 
munity with a wealth of childlore and games, but such is not the case. 
They only play what they have in common, and these are the most 
elementary games suited only to the younger children. This condition 
with reference to the absence of adequate traditions carrying suitable 
plays applies to the country and village districts as much as it does 
to the cities. The play of our country children is about as inadequate 
as is that of our city children. This is not a matter of poverty. The 
exquisitely dressed children led by the hand along Riverside Drive, 
New York, in order that they may "get the air" are a more pathetic 
sight than are the equally healthy though dirty children one sees play- 
ing on the East Side. That these conditions are actually resulting in 
decreased power to live is shown by several extensive studies made in 
Great Britain during the past decade. 

We have massed here several groups of facts bearing more or less 
closely on the alterations of children's lives that have occurred or are 
occurring to show the situation that is back of the movement for physical 
training, playgrounds, etc., in departments of education. 

The state provides for the education of all citizens as a measure 
of self-protection. The facts given show that the state must also take 
cognizance of their physical welfare for the same reason. Health and 
education belong hand in hand. This means that the existing educa- 



Nature and Aims of Medical Inspection ii 

tional agencies must ally with themselves expert medical officers who 
shall see that the health of children is conserved through the schools. 
This cannot be an incidental activity of some department, but must 
outrank all others in power, as it does in importance. 

Medical inspection, then, aims at both the protection of thecommunity 
and furnishing the physical conditions under which wholesome life can 
develop. It involves in this comprehensive aim the functions of both 
the departments of health and of education. 



CHAPTER II 

The Argument for Medical Inspection 

Since the days of Juvenal, men have been quoting his much abused 
half-Kne, "A sound mind in a sound body"; and while making diligent 
provisions for schools in which "sound minds" were to be shaped, have 
felt that these schools needed little scrutiny as to their fitness for con- 
serving and developing "sound bodies". 

The famous Spanish voyager who lost his life in his futile search 
for the phantom fountain of youth was far from being the first or the 
last of the long line of seekers for a "cure-all" which should eradicate 
the ailments of old age and restore that buoyant health of youth which 
modern science is just beginning to teach us must be dihgently con- 
served from childhood, if it is to be enjoyed in after-Hfe. 

To say that we have during all this time lost sight of the true source 
of a healthy old age would be an extreme statement, but it is certainly 
true that educators in general have given but scanty and fleeting atten- 
tion to the problem of the physical well-being of their charges. 

All too often the same complacent and care-free attitude of mind 
has been shared by the parent. All children had to have the " common 
children's diseases" — and the sooner, the better. If Johnny breathes 
through his mouth — "He always did that. He will outgrow it." The 
child's cough is only "a slight cold." "He always turns his head to 
one side when he writes or reads. It's a habit he has got into. He 
has always been pale. It is nothing unusual." 

In cases of serious epidemics it has always been recognized that 
parents have the right to insist that the schools shall be safe places 
for them to send their children. This right has been recognized by the 
closing of the public schools during an epidemic; but despite the fact 
that it has long been recognized that the pubHc school serves as a center 
of exchange for contagious diseases which pass from pupil to pupil, 



The Argument for Medical Inspection 13 

the occasional closing down and the rare fumigation have constituted 
the sum total of preventive measures, with the single exception of the 
commonly insisted on requirement of vaccination. 

Again, except in extreme cases, the school has taken little note of 
such defects of mind and body as might vitally affect the chances of 
success and happiness of the child, unless such defects were of the more 
directly alarming nature of contagious diseases. 

The "lockstep" has been the rule in physical matters, as in the 
realm of the course of study. All the children have been received on an 
equality and have been treated equally, no matter what their mental 
endowments or physical condition. The quick and the slow, the sound 
and the sick, have been grouped together; and he who could not keep 
his place in his studies has been as unquestioningly left behind as has 
he who through illness could not retain his place in the school. 

That such a course was poor business policy, based on the false 
assumption of a universal mental and physical equality which does not 
exist, has been pointed out times without number. As in all movements, 
the leaders have been far in advance of the rank and file; and in our 
own, as in other countries, the great majority of people have been too 
much engaged in their special interests to give heed to the great problems 
involved in the work of improving the educational and physical well- 
being of the young of the race. 

With the great changes which have been coming over American 
life, former conditions have disappeared and this undisturbed indifference 
has become impossible. We have changed from an agricultural people 
to a race of dwellers in towns and cities. The school year has changed 
from a three months' winter term to one of five hours per day for ten 
months during the year. The number of years of school life has greatly 
increased. We have passed compulsory education laws. Going to 
school has become not only the normal, but the required occupation 
of all children for a considerable number of years. 

The results of these changed conditions on the health of children 
have become so marked as to insistently demand attention. The 
parents, school authorities, and health authorities have been unable 
to avoid recognizing the fact that in the nature of the case the school 
has become the most certain center of infection in the community. 

From these conditions grew up medical inspection, for the purpose 



14 Medical Inspection of Schools 

of detecting cases of contagious diseases and of segregating such cases 
for the protection of other children. Wherever estabhshed, the good 
results of medical inspection have been evident. Epidemics have 
been checked or avoided. Improvements have been noted in the 
cleanliness and neatness of the children. Teachers and parents have 
come to know that under the new system it is safe for children to con- 
tinue in school in times of threatened or actual epidemic. 

But medical inspection does not stop here, nor has it limited its 
activities to the field outlined. Other problems have been insistently 
forcing themselves on the attention of school men; and they, knowing 
something of the wonderful advances made in the field of medicine, 
have turned for aid to the physicians. 

With the changes in the length of the school term and the increase 
in the number of years of schooling demanded of the child, has come 
a great advance in the standards of the work required. When the stand- 
ards were low, the work was not beyond the capacity of even the weaker 
children; but with close grading, fuller courses, higher standards, 
and constantly more insistent demands for intellectual attainment, 
this has changed. Pupils have been unable to keep up with their classes. 
The terms "backward," "retarded," "exceptional" as applied to school 
children have been added to the vocabularies of the school men. In- 
quiries have been instituted into the causes underlying the phenomena 
of backward and retarded children, of those who are unable to keep up 
with their classes, or those who seem to be different from their com- 
panions in their ability to do the work demanded. 

As a result of these inquiries, physical examinations have been 
conducted by the doctors connected with the schools. Surprising num- 
bers of children have been found who through defective eyesight have 
been seriously handicapped in their school work. Many are found 
to have defective hearing. Other conditions are found which have 
a great and formerly unrecognized influence on the welfare, happiness, 
and mental vigor of the child. Attention has been directed to the 
real significance of adenoids and enlarged tonsils, of swollen glands 
and carious teeth. 

Persistently, earnestly and quietly this work has been pushed to a 
successful experimental accomplishment, and as a result we have to-day 
medical inspection in its various forms — not only for the detection of 



The Argument for Medical Inspection 15 

contagious disease, but also for discovering those physical defects 
which interfere with the child's ability to do his school work, or which, 
if neglected, will seriously affect his physical efficiency in after-life. 
The movement as a whole constitutes both a sign and a result of the 
gradual awakening which has developed into a wave of interest in 
matters that pertain to the health of school children that is now sweep- 
ing over the civilized world. 

Communities are seeing the whole matter in a new light. Gradually 
they are beginning to ask — not whether they can afford to take steps 
to safeguard in schools the welfare of their children, but whether they 
can afford not to take such steps. The realization is dawning that it 
is unbusinesslike to count carefully the cost of the school doctor, but to 
disregard the cost of death and disease, of wrecked hopes and dependent 
families. 

Teachers and parents are commencing to realize that from their 
viewpoint and from that of the school physician the problem of the 
pupil with defective eyesight may be quite as important to the com- 
munity as that of the child who has some contagious disease. This 
child, placed in a school where physical defects are unrecognized and 
disregarded, is unable to see distinctly, and headaches, eye-strain, and 
failure follow all his efforts at study. He cannot see the blackboards 
and charts, printed books are indistinct or are seen only with much 
effort — everything is blurred. Neither he nor his teacher knows what 
is the matter, but he soon finds it impossible to keep pace with his 
companions, and, becoming discouraged, he falls behind in the unequal 
race. 

In no better plight is the child suffering from enlarged tonsils and 
adenoids, which prevent proper nasal breathing and compel him to 
keep his mouth open in order to breathe. Perhaps one of his troubles 
is deafness. He is soon considered stupid. This impression is strength- 
ened by his poor progress in school. Through no fault of his own 
he is doomed to failure. He neglects his studies, hates his school, 
leaves long before he has completed the course, and is well started on 
the road to an inefficient and despondent life. 

Public schools are a public trust. When the parent delivers his 
child to their care, he has a right to insist that the child under the super- 
vision of the school authorities shall be safe from harm and will at 



1 6 Medical Inspection of Schools 

least be handed back to him in as good condition as he was at first. 
Not only has the parent the right to claim such protection, but even 
if he does not insist upon it, the child himself has a right to claim it. 
The child has a claim upon the state and the state a claim upon the 
child which demand recognition. In the words of Dr. WilHam H. 
Allen: "When the state for its own protection compels a child to go 
to school, it pledges itself not to injure itself by injuring the child." 
We are beginning to find out that many of our backward pupils are 
backward purely and simply because, through physical defects, they 
are unable to handle the work of the school program. What these 
defects are and the causes that lie behind them are things that we must 
know. If we do not know them, we must find them out and guard 
against them. Education without health is useless. It would be better 
to sacrifice the education if, in order to attain it, the child must lay 
down his good health as a price. Education must comprehend the whole 
man and the whole man is built fundamentally on what he is physi- 
cally. Children are not dullards or defectives by the will of an inscru- 
table Providence, but rather by the law of cause and effect. 

The objection that the state has no right to permit or require medical 
inspection of the children in the schools will not bear close scrutiny nor 
logical analysis. The authority which has the right to compel attendance 
at school has the added duty of insisting that no harm shall come to those 
who go there. The Massachusetts law, with its mandatory " shall, " is 
certainly preferable to the New Jersey law, with its permissive "may." 
The exercise of the power to enforce school attendance would be dan- 
gerous if it were not accompanied with the appreciation of the duty 
of seeing that the assembling of pupils brings to the individual no physical 
detriment. When the subject is considered both from the standpoint 
of the individual and from that of the state, the wonder is not that 
medical inspection is now being agitated, but rather that it was not 
long ago put into practice. 

Nor is the state, in assuming the medical oversight of the pupils 
in the public schools, trespassing upon the domain of private rights and 
initiative. American systems do not, like the feeding of school children 
(already resorted to in France and in parts of England), lessen the respon- 
sibility of the parent or tend to weaken or supersede the home. Under 
medical inspection absolutely nothing is done for the parent but to tell 



The Argument for Medical Inspection 17 

him of the needs of his child, of which he would otherwise have been 
in ignorance. It leaves it to the parent to meet those needs. It leaves 
him with a larger responsibility than before. Whatever view be taken 
of the right of the state to enforce measures for the correction of defects 
discovered, the arguments for and against do not enter into the present 
discussion. It seems difficult to find a logical basis for the argument 
that the state has not the right to inform the parents of defects present 
in the child, and to advise as to remedial measures which must be taken 
to remove them. 

The justification of the state in assuming the function of education 
and in making that education compulsory is to insure its own preserva- 
tion and efficiency. Whether or not it is to be successful will depend 
on its individual members. But the well-being of a state is as much 
dependent upon the strength, health, and productive capacity of its 
members as it is upon their knowledge and intelligence. In order that 
it may insure the efficiency of its citizens, the state through its compulsory 
education enactments requires its youth to pursue certain studies which 
experience has proved necessary to secure that efficiency. Individual 
efficiency, however, rests not alone on education or intelligence, but is 
equally dependent on physical health and vigor. Hence, if the state 
may make mandatory training in intelligence, it may also command 
training to secure physical soundness and capacity. 

Much time may elapse before there will be brought to bear in all 
schools the measures, now so successfully pursued in some, for conserv- 
ing and developing the physical soundness of rising generations. But, 
nevertheless, the movement is so intimately related to the future welfare 
of oiu: country and is being pushed with so great energy and earnestness 
by its advocates that it is destined to be successful and permanent. 

Not alone our unwillingness to be outdone in this public service 
by foreign nations, not alone our sense of practical foresight, but our 
inherent feeling of obligation toward our children and our recognition 
of this service as one of necessity for the national well-being, are forcing 
upon us the incorporation of this phase of public activity as an integral 
part of our public education. 



CHAPTER III 

Historical 

A Sketch of the Rise, Development and Present 
Status of Medical Inspection at Home and Abroad 

Medical inspection of schools is a movement of recent growth, 
although it is by no means in its infancy and has long since passed 
its experimental stage. 

In France the law of June 28, 1833, charged the school committees 
of the cities and towns with the care of keeping the school houses clean, 
while a royal ordinance of December 22, 1837, made it the special duty 
of the female supervisors of maternal schools (kindergartens) to 
watch over the health of the little children. In Paris separate govern- 
mental decrees were issued. The decrees of 1842 and 1843 ordered 
that every public boys' and girls' school should be visited by a physician 
who was to inspect the localities and the general health of the school 
children. This arrangement, while praiseworthy in purpose, had the 
great drawback of not being supported by the annual budgets. Hence 
an appeal to the generosity of the medical fraternity was necessary. 
Many physicians offered their services and gave them gratuitously for 
years. 

In 1879 the General Council of the Department of the Seine voted 
to reorganize the medical service in the schools and passed an appro- 
priation for the payment of salaries to the physicians. The department 
was divided into 114 districts, of which 88 were within the city of Paris. 
A physician was placed in charge of the work in a district, and each 
district contained from 20 to 25 school rooms. In January, 1884, the 
service was again reorganized. Needed regulations were drawn up 
and the districts were changed so as to give each inspector from 15 to 
20 school rooms. It is from this year — 1884 — that the present institu- 
tion of medical supervision of schools in Paris dates. 



Historical 



19 



The organization there has served as a model for similar arrange- 
ments in other French cities. Through the school law of 1886, as 
well as through ministerial decrees and orders dated 1887, medical 
and sanitary inspection has been made obligatory in all French schools, 
public and private. To the city of Havre belong the honor and credit 
of having the first free public dispensary for children. It was founded 
in 1875. 

Probably the first system of medical inspection in the full modern 
sense of the term was that inaugurated in Brussels in Belgium in 1874, 
when school physicians were appointed who were required to visit 
schools three times per month. So successful did the system prove 
that it was soon copied in Antwerp, Louvain, Liege, and other cities, 
and served as a model for systems in Switzerland. Moreover, in view 
of the favorable results in Brussels, dentists and oculists were likewise 
appointed to visit the pupils regularly. 

In Germany, Leipsic and Dresden were the first cities to have 
medical inspection. A beginning was made in Dresden in 1867, when 
three physicians, formerly teachers of physical training, were intrusted 
with the examination of children in cases of epidemic eye disease; but 
these were not fully equipped school physicians. Not until i88g was 
a system of true medical inspection established. The movement spread 
rapidly and was taken up by city after city. In Wiesbaden a system 
was developed providing for a careful and thorough physical examination 
of each child at the time of entering school, and for a re-examination 
in the third, fifth, and eighth years of the public school course. The 
system also provides for careful service for the detection of contagious 
diseases and for the inspection of school buildings and surroundings. 
In 1898 the Wiesbaden method of school inspection was generally 
adopted throughout Germany. 

Wiesbaden Plan of School Inspection 

With the introduction of the Wiesbaden method of school inspection 
began a new epoch in the development of the school systems of Ger- 
many. The chief characteristic of this method lies in a strong emphasis 
upon the hygiene of the school child, without in any way neglecting the 
hygiene of the school building. Medical inspection in the schools 



20 Medical Inspection of Schools 

of Germany, which previous to the introduction of this plan had lagged, 
has since its adoption gained rapidly. 

Wiesbaden was the first German city to make a test examination 
of all pupils, whereby an unusually high percentage of defects was 
revealed, of which the pupil, the teacher, and the parents were wholly 
ignorant. It became apparent to the Wiesbaden authorities that a 
medical examination of at least all children entering school was of the 
utmost importance. The result of the trial examination led to the 
establishment of a system of regular examinations. 

The provisions of the Wiesbaden plan are: systematic examination 
of heart, lungs, throat, spine, skin, and the higher sense organs (and 
in the case of boys also examination for hernia). The findings are 
entered on a report blank, which accompanies the child from grade to 
grade in his school life. Twice a year the teacher records the height 
and weight of individual pupils. Wherever it is deemed necessary, 
the school physician takes chest measurements. The records of children 
who seem to require the regular care of a physician are marked accord- 
ingly, and these children report at regular intervals to the school physi- 
cian. A careful re-examination of all pupils must be made in their 
third, fifth, and eighth school years. It is the duty of the school physi- 
cian to give advice to the teacher with reference to the child. In cases 
of defects requiring medical attention, the parents of the child are 
notified. It is not the fimction of the school physician to give treat- 
ment. 

In Hungary the law of 1887 provided for school physicians to visit 
the institutions of learning. Their duties are: the hygienic supervision 
of school rooms, the detailed examination of all children entering school, 
and the giving of lectures in the schools with reference to hygiene. 

In Austria medical inspection of schools is an affair of the state. 
In the different crown lands it is under the Provincial Councilor of 
Education, in the school districts under the district school boards, and 
in the different communities under the local school boards. 

In Norway the instructions have been enforced since 1899, to the 
effect that with the consent of the local administration, a physician 
may inspect the health of school children; but by the decree of Septem- 
ber 24, 1891, this regulation was extended so that the health of pupils 



Historical 2i 

must be examined three times per year, — in May, August, and Decem- 
ber, — and the report drawn up in prescribed form by the board of 
teachers and physicians, who are to give special attention to the causes 
of absences from school, headache, and fatigue. 

Sweden is probably the country where the term "school physician" 
in the modern sense was first employed, though at first the duties of 
school physicians did not comprehend the work done by them at the 
present day. In 1863 they were only obliged to examine with reference 
to exemption from gymnastic exercises. In 1874 committees on health 
were given charge of the schools, especially with reference to ventilation, 
and since 1878 school physicians have been required to examine the 
health of children at the beginning of the term and to report the results. 

In Roumania, by the decree of April 5, 1899, special physicians are 
required, either themselves or in the persons of district physicians, to 
examine all school children at least once a year; to inspect buildings 
with reference to construction and equipment (heating, light, cleanliness, 
drinking-water, privies, etc.); to supervise all that touches in any way 
on the subject of health, and to submit propositions to the proper authori- 
ties for supplying existing wants and remedying evils. 

Moscow has had school physicians in her schools since 1888. It 
is the duty of these physicians to examine all the pupils once a year 
and to make reports on the "sanitary lists" of the children. Since 
1895 six physicians have been in charge of health matters in the 72 
elementary schools, and since 1888 two female physicians have been 
employed at the girls' high school. Besides their other functions, 
these physicians are required to vaccinate and revaccinate, to treat poor 
sick pupils free of charge, and to manage affairs in cases of epidemics. 

In Switzerland medical inspection has become a national movement, 
although governed by different regulations in the several cantons. 

In England the medical inspection act, which went into effect January 
1, 1908, is national in its scope and applies to all the public elemen- 
tary schools. It is thorough in its provisions for a complete system 
of medical supervision. Its high purposes are expressed in a memoran- 
dum of the Board of Education, in the following words: 

"It is founded on a recognition of the close connection 
which exists between the physical and mental condition 



22 Medical Inspection of Schools 

of the children, and the whole process of education. It 
recognizes the importance of a satisfactory environment, 
physical and educational, and by bringing into greater 
prominence the effect of environment upon the personality 
of the individual child, seeks to secure ultimately for every 
child, normal or defective, conditions of life, compatible 
with that full and effective development of its organic 
functions, its special senses, and its mental powers, which 
constitute a true education." 

For the purpose of putting into operation the provisions of this act, 
the county educational committees throughout England have been 
taking active steps in creating the necessary machinery and perfecting 
existing organizations of medical officers. Already there is a national 
Society of Medical Officers for Schools. 

In France such a society has long existed and has now reached a 
degree of strength and importance which has prompted it to begin the 
publication of a monthly entitled, "La Medecine Scolaire," the bulletin 
of the Society of Medical Inspectors of Schools. Volume I, No. i, 
appeared on February lo, 1908. The deep purpose which actuates 
the leaders of the movement in France is expressed in the introductory 
editorial of the first number of the magazine. The editorial is entitled, 
" Our Program," and begins as follows: 

"The purpose of protecting children and of assuring 
them their best physical and intellectual development has 
for several years been assuming an ever-increasing impor- 
tance. In this movement in favor of all that pertains to 
conserving the health of children — in the work which 
Prof. Pinard has called ' puericulture ' — France has taken 
an important part. Indeed, for France this has become 
a most important duty, because the study of these ques- 
tions has a higher importance in this country than in more 
favored countries, where the question of the increase of 
population does not constitute one of the vital problems 
of the day." 

After going on to describe the purposes of the Association of School 



Historical 23 

Medical Inspectors, and after studying some of the important work 
done by the society in the past, the publication of the new journal is 
introduced with the words, " To-day the Society of Medical Inspectors 
of Schools wishes to complete its work by the publication of the journal, 
^ La Medecine Scolaire.' " 

But Europe and America are not the only parts of the world that 
have been receiving the benefits of medical inspection. Since 1882 
in Cairo, Egypt, a school physician has been employed at a salary of 
12,000 francs, besides two assistants, each with a salary of 3600 francs, 
having the supervision of 5000 pupils. 

In Chile in 1888 the supervision of schools was intrusted to a Provin- 
cial Coimcil, including a physician as a member, and the supreme 
direction of sanitary affairs was given in charge of a superior board of 
public health, composed of seven members. School physicians in 
Chile are required to visit each school at least once a month, inspect 
the sanitary condition of buildings and surroundings, inform them- 
selves of the condition of health among the children, make note of their 
observations, and hand in a monthly report. 

In the Argentine Republic great interest in medical inspection 
has been manifested, and the system is credited with being one of the 
most complete and efl&cient in existence. It provides for the vaccina- 
tion of school children, examination of the sanitary condition of school 
buildings, the visiting of sick children in their homes, the prevention 
of contagious diseases, the delivering of regular scientific lectures, and 
the giving of free medical advice to the teachers as well as to the pupils. 

In Japan in 1898 the Minister of Education directed the nomination 
of salaried school physicians in all public schools. Frederick J. Haskin, 
writing of the work there in 1898, says: 

"The Japanese system of medical inspection extends 
all over the empire and reaches the most remote rural 
community. Thus the Japanese department of education 
is able to tell how many children are in school in the 
empire, how many are robust, medium, or weak, how 
many have defective eyesight, and what diseases are most 
prevalent at different ages of school life. The department 
can also tell how many children in school at the age of 



24 Medical Inspection of Schools 

fifteen years were 150 cm. tall, how many weighed 40 kg., 
and how many had a chest measurement of 75 cm. They 
can also tell the averages of all these statistics and the 
percentages of robust boys or fat girls." 

In the United States the first regular system of medical inspection 
seems to have been in Boston in 1894. Before this, however, in New 
York in 1892, Dr. Cyrus Edson, then Sanitary Superintendent, appointed 
Dr. Moreau Morse, Medical Inspector of Schools. Dr. Morse was 
probably the first public medical school officer to be appointed in this 
country. 

In Boston the need of medical inspection of schools, for the purpose 
of detecting contagious and other diseases among the school children, 
was brought to the attention of the mayor and city council in 1892; 
and for this purpose an appropriation was then secured. A delay of 
several months was occasioned in securing the approval of the school 
committee, so that the plan did not finally go into operation until Novem- 
ber, 1894, when the Board of Health selected 50 physicians for this 
purpose, divided the city into 50 school districts, and began school 
inspection. 

In New York the Board of Health, at a meeting held March 16, 
1897, appointed 134 medical inspectors for public schools. Dr. A. 
Blauvelt, formerly assistant chief of the Bureau of Contagious Diseases, 
was appointed chief inspector at an annual salary of $2500. 

Chicago in 1895 was divided into nine districts for the purpose of 
the inspection of schools. One medical inspector was assigned to each 
district, giving each inspector an oversight of more than 20 square 
miles. 

In Philadelphia the Bureau of Health passed the following resolu- 
tion on June 7, 1898: 

"Resolved that the medical inspector be directed to 
have the 15 assistant medical inspectors visit one public 
school each day in their respective districts, who shall 
inspect each school according to the methods now em- 
ployed in Boston, New York, and Chicago." 



Historical 25 

Since its first inception in Boston, the movement for medical inspec- 
tion has rapidly spread in the United States, and in many states has 
developed from mere inspection for the detection of contagious diseases 
to systems embracing most thorough physical examinations. 

Fovir state laws have been passed. In 1899 the legislature of 
Connecticut passed a law providing for the testing of eyesight in all 
the pubHc schools of the State. Under this law the State Board of Edu- 
cation is required to furnish test-cards and blanks, and instructions 
for their use, to the school authorities. The superintendent, principal, 
or teacher in every school is required to test the eyesight of all the 
pupils during the fall term, and notify in writing the parent or guardian 
of every pupil who has any defect of vision, with a brief statement 
of each defect. 

New Jersey has a statute which went into effect in 1903. It autho- 
rizes boards of education to employ competent physicians as medical 
inspectors of schools. It also defines the duties of the medical inspector. 
The law is permissive and not mandatory in its provisions. 

Vermont followed in 1904, with a law requiring the examination 
of the eyes, ears, and throats of school children annually. 

In 1906 the legislature of Massachusetts passed a law providing for 
a system of medical inspection throughout the State. According to 
its provisions every town and city must establish and maintain a system 
of medical inspection with competent physicians for the detection of 
contagious diseases. Examinations are conducted annually by the 
physicians for the detection of non-contagious physical defects, and 
eyesight and hearing tests are made each year by the teachers. The 
law is mandatory, not permissive, in its provisions. 

Without authoritative and specific enactment, the State Boards of 
Health of New York, Utah, and California have conducted examinations 
of the eyesight and hearing of school children. 

At the present time — 1908 — there are in operation, so far as can be 
ascertained, systems of medical inspection in some form in the following 
70 cities outside of Massachusetts. (As in this State medical inspection 
is obligatory under the state law, systems exist in practically every city.) 



26 



Medical Inspection of Schools 



CITIES OF THE UNITED STATES, OUTSIDE OF MASSACHUSETTS, 

HAVING SOME FORM OF MEDICAL INSPECTION 

OF SCHOOLS, JUNE, 1908 

City. State. Controlling Authority. 

Albany New York Albany County Medical Society. 

Ann Arbor Michigan Board of Education. 

Asbury Park New Jersey 

Atlantic City New Jersey . . . 

Baltimore Maryland " " Health. 

Buffalo New York ' 

Camden New Jersey ' 

Chicago Illinois ' 

Cincinnati Ohio ' 

Cleveland Ohio ' 

Dallas Texas ' 

Dayton Ohio 

Detroit Michigan 

Des Moines Iowa Polk Co. Medical Association 

Elgin Illinois Board of Health. 



Education. 
Health. 



Education. 
Montgomery Co. Medical Society. 
Board of Health. 



Englewood New Jersey " 

EvansviUe Indiana " 

Fort Dodge Iowa " 

Fort Worth Texas 

Galveston Texas " 

Grand Rapids Michigan " 

Hackensack New Jersey " 

Harrisburg Pennsylvania. . 



Education. 



" Health. 



. . " " School Trustees. 

. . " " Education (Nurses only). 

. . " " Health. 

.Dr. C. S. Rebuck, and Visiting Nurse 
Association. 

Hartford Connecticut Board of Health. 

Hazelton Pennsylvania Board of Education 

Houston Texas Houston Association of Opticians and 

Aurists. 

Jersey City New Jersey B oard of Education (Nurses only) . 

Lansing Michigan Volunteer work 

Lincoln Nebraska 

Long Beach California 

Los Angeles California Boards of Education and Health. 

Milwaukee Wisconsin Milwaukee Medical Society. 

Minneapolis Minnesota Associated Charities and Women's Club. 

Montclair New Jersey Board of Health. 

Mount Holly New Jersey 

Newark New Jersey Boards of Health and Education. 

New Haven Connecticut Board of Health. 

Newport Rhode Island.; " " ' 



Historical 27 

Cities of the United States, Outside of Massachusetts, Having Some 
Form of Medical Inspection of Schools, June, 1908 (Continued) 

City. State. Controlling Authority. 

New Orleans Louisiana Board of Education 

New York City New York " " Health. 

Norristown Pennsylvania 

Ogden Utah 

Orange New Jersey Board of Education 

Pasadena California " " " 

Passaic New Jersey " " " 

Paterson New Jersey " " " 

Philadelphia Pennsylvania " "Health 

Plainfield New Jersey " " " 

Port Chester New York 

Portland Oregon 

Providence Rhode Island Board of Health. 

Reading Pennsylvania Volunteer work 

Rochester New York Board of Health. 

Salt Lake City Utah " " 

San Antonio Texas " "Education. 

Schenectady New York 

Seattle Washington " "Health. 

Sioux City Iowa Volunteer work. 

St. Joseph Missouri 

St. Louis Missouri 

Superior Wisconsin 

Syracuse New York Board of Health. 

Union Hill New Jersey .... " " Education. 

Washington District of Columbia Board of Health. 

Waterbury Connecticut " " " 

Waverly Rhode Island 

Westchester Pennsylvania 

White Plains New York Board of Health. 

Wilmington Delaware " " Education 

Woonsocket Rhode Island " " " 

The work in Massachusetts includes 32 cities and 321 towns. At 
the beginning of the present year it was reported from Massachusetts 
that boards of health had begun the work in 22 cities and 47 towns 
and boards of education in 10 cities. No reports were received from 
the remaining towns. 

The foregoing brief account of the history of medical inspection 
and its present status serves to give an idea of the firm basis on which 



28 Medical Inspection of Schools 

the movement rests in other comitries, and the prominent place accorded 
it in educational esteem. In America the movement has been some- 
what tardy in arriving, but its spread has been rapid, and now that 
it has passed the experimental stage, its permanency is assured. 

Statistics and observation have shown the great prevalence of con- 
tagious diseases among school children. Investigations have revealed 
the large percentage of children suffering from non-commimicable 
physical defects. Whether or not the home is responsible for a large 
part of the conditions and how far they are aggravated by the conditions 
of school life are questions of ultimate importance, but not calling for 
immediate solution. The important condition confronting American 
educators and social workers is that the school furnishes an unrivaled 
opportunity for detecting and checking diseases and defects among 
children. The problem of caring for those found to be defective or 
ill, and of preserving the health of those who are physically sound, 
is one of the utmost importance. Given the importance of the problem 
and the good examples set abroad, there can be no doubt that rapid 
additions will be made to the list of American cities having systems 
of medical inspection of schools, and that those systems themselves 
will rapidly become broader in scope and more thorough in method. 



CHAPTER IV 

Inspection for the Detection of Contagious 

Diseases 

Nearly all systems of medical inspection in America have had for 
their object at the time of their inception merely the detection in their 
early stages of cases of contagious diseases. To this simple aim has 
always been shortly added the detection and exclusion of parasitic 
diseases. Conducting examinations for the detection of physical 
defects is a further development of the work and is still far from general. 
In towns and small cities medical inspection for the detection of 
contagious diseases is a comparatively simple matter involving few 
difficuhies in organization or administration. 

In such places the teacher who thinks she sees suspicious symptoms 
in one of her pupils and fears they may portend the beginning of some 
illness notifies the principal of her fears. He notifies the school physician 
by telephone or messenger and the physician goes to the school and 
examines the pupil, sending him home if necessary. Of course such 
simple systems require little in the shape of blanks or forms. Notifica- 
tion cards or blanks are used for informing the parent of the exclusion 
of the child, and weekly or monthly reports are made out by the school 
physician stating how many children he has examined, how many he 
has excluded and for what diseases, and what other diseases he has 
found which did not require exclusion. 

A sample of such a simple exclusion card is the one in use in Brockton, 
Mass. (see p. 30). 

The monthly report of the medical inspector of the same city (see p. 31) 
is also a good sample of the forms found satisfactory in simple systems 
and which might well be adapted for use in any town where the number 
of cases handled is comparatively small and the pupils are individually 
known to the school authorities and it is easy to keep track of them. 

29 



30 Medical Inspection of Schools 

EXCLUSION CARD. BROCKTON, MASS. 

CoinTnonwcaltb of jVlasdachusetts* 

CONTAGIOUS DISEASE. 
NOTICE TO PARENT OR GUARDIAN. 

In accordance with Chapter 502 of the Acts of 1906, you are 

hereby notified that 

has been examined hy me as School Physician, and found to have 
symptoms of 

This child is excluded from the schools until he brings a state- 
ment from a regular practitioner certifying his complete recovery. 

School Physician. 

190 

As systems increase in size or it is found desirable to make them 
more thorough, difficulties increase and a more complex organization 
is found necessary. Probably the most complete and thoroughly 
organized system in the United States is that of New York City. While 
many of its features would be found unnecessary in other places, some 
of them would prove applicable anywhere. It therefore seems worth 
while to describe it at some length and to give as well a brief summary 
of its development since 1897, when the work was begun. The following 
account is largely taken from the report of the Department of Health 
of New York for the year ending December 31, 1906. The report was 
pubhshed November 30, 1907. 

THE MEDICAL INSPECTION AND EXAMINATION OF SCHOOL 

CHILDREN 
HISTORY 

March, 1897: Appointment of one hundred and fifty Medical 
Inspectors, at a salary of $30.00 per month. Morning inspec- 
tion only required. 

September, 1902 : System elaborated to include morning inspection, 



MONTHLY REPORT OF MEDICAL INSPECTOR. BROCKTON, 

MASS. 



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32 Medical Inspection of Schools 

routine weekly inspection of children in the classrooms 

and visiting of absentees at their homes. Salary of Inspectors 

increased to $100.00 per month. 
December i, 1902 : Appointment of a corps of Trained Nurses, 

at a salary of $75.00 per month. 
December 16, 1902 : Establishment of a Hospital and Dispensary 

for the exclusive treatment of cases of Trachoma. 
March 27, 1905 : Inception of complete physical examination 

of each school child. 

OBJECTS 

1. Repeated and systematic inspection and examination of school 

children to determine the presence of infectious or conta- 
gious diseases. 

2. Exclusion from school attendance of all children affected with 

acute contagious disease. 

3. Subsequent control of the case, with isolation of the patient 

and disinfection of the living apartments after termination 
of the illness. 

4. Control and treatment of minor contagious affections, per- 

mitting the child to remain in attendance at school. 

5. Information of unreported cases of contagious disease occurring 

in school children at their homes. 

6. Exclusion from school attendance of those children in whose 

families there exists a contagious disease. 

7. Complete physical examination of each school child for the pur- 

pose of determining the existence of non-contagious affections 
and advising treatment of same. 

SCHOOLS VISITED 

Public Schools, Parochial Schools, American Female Guardian 
Society Schools, Children's Aid Society Schools and Kinder- 
gartens. 

FORCE 

1. Assistant Chief Medical Inspector, in charge of work. 

2. Corps of Medical Inspectors, all of whom are physicians. 

3. Supervising Nurse, in direct charge of the nurses. 

4. Corps of Trained Nurses. 



Inspection for Detection of Contagious Diseases 33 

WORKING PLAN OF THE SYSTEM 
Duties of Medical Inspectors 

Each Inspector is assigned to duty in a group of schools 

I. Morning Inspection 

Inspector visits each school in his charge before ten o'clock 
each morning, and examines, in a room set apart 
for this purpose, the following: 

(a) All children isolated by the teachers as suspected 
cases of contagious diseases. 

(b) All children who have been absent from school. 

(c) Children returning after previous exclusion. 

(d) Children previously ordered imder treatment. 

(e) All affected children referred by the school nurse for 

diagnosis. 
(/) All affected children showing no evidence of treatment. 
Cases to be Excluded 

(a) Children showing signs or symptoms of smallpox, 
diphtheria, scarlet fever, measles, chicken-pox, whoop- 
ing-cough or mumps. 

(b) Cases of pediculosis, with live pediculi. 

(c) Skin diseases, including ringworm of scalp, face 
or body, scabies, dormant pediculosis, in cases where 
the children have persistently refused to undergo 
treatment. 

Cultures are taken in all cases of sore throat to determine the presence 
of the diphtheria bacillus. 

Cases of smallpox, scarlet fever and measles are reported, by tele- 
phone, to the Central Office, so that a diagnostician may at once visit 
the case, confirm the diagnosis and order isolation. In these cases a 
postal card is sent from the Division of Contagious Diseases to the 
Principal of the school informing him, or her, of the presence of con- 
tagious disease, with instructions that no member of the family be 
allowed to attend school vmtil the termination of the case. The following 
is the form used: 



34 Medical Inspection of Schools 

POSTAL CARD 

department of ^ealtfi. 

NEW YORK CITY. 
DIVISION OF CONTAGIOUS DISEASES. 

New York, 190 

The following-named children, pupils of your 

school, are exposed to the contagion of 

at 



Sec. 145. No principal or superintendent of any 
school, and no parent, master or custodian of any 
child or minor (having the power or authority to pre- 
vent) shall permit any child or minor having scarlet 
fever, diphtheria (croup), smallpox, or any dangerous, 
infectious, or contagious disease, or any child in any 
family in which any such disease exists or has recently 
existed, to attend any public or private school until 
the Board of Health shall have given its permission 
therefor, nor in any manner to be unnecessarily 
exposed, or to needlessly expose any other person 
to the taking or to the infection of any contagious 
disease. 

Respectfully, 



Chief Medical Inspector. 
Reported by 



Medical Inspector. 

Cases to be Referred to Their Own Physician, a Dispensary 

or to the School Nurses for Treatment 
(a) Acute conjunctivitis. 
(h) Pediculosis, 
(c) Skin diseases, including ringworm of scalp, face or 

body, scabies, favus, impetigo and molluscum 

contagiosum. 



Inspection for Detection of Contagious Diseases 35 

These children are re-examined the following day and allowed to 
attend school as long as treatment is continued. Children affected 
with trachoma are referred to their own physicians or to dispensaries 
for treatment, and are allowed to attend school as long as evidence of 
treatment can be shown. 

Each excluded child is furnished with an official exclusion card, 
properly filled out, as follows: 



EXCLUSION CARD, SHOWING FACE 

DEPARTMENT OF HEALTH, 

BOROUGH OF MANHATTAN. 

New York, 190 

Name Age 

Address 

IS ORDERED TO DISCONTINUE ATTENDANCE at 

School No , located at 

REASON: 



Medical Inspector. 
(see other side) 



EXCLUSION CARD, SHOWING REVERSE 

NOTICE TO PARENTS. 



The disease mentioned on the other side of this card is a contagious 
affection and liable to be transmitted to other children. The child 
should receive prompt treatment by any physician (or at any dis- 
pensary), and should return to school , igo . ., 

for re-examination by the Medical Inspector of the Department of 
Health. If found free from contagion at this time, he may resume 
attendance at school. 



36 Medical Inspection of Schools 

Each pupil referred to the nurse for treatment receives from the 
medical inspector a slip on which is written the code number indicating 
the diagnosis of its affection. 



CODE CARD, SHOWING NUMBERS INDICATING DISEASES 

Code 



I. Diphtheria, 


12. Varicella, 


2. Pediculosis. 


13. Pertussis, 


3. Tonsillitis. 


14. Mumps, 


4. Pediculosis. 


15. Zero. 


5. Acute Conjunctivitis. 


16. Scabies. 


6. Pediculosis. 


17. Ringworm. 


7. Trachoma. 


18. Impetigo. 


8. Pediculosis. 


19. Favus. 


9. Zero. 


20. MoUuscum Contagiosum, 


10. Scarlet Fever. 


21, Acute Coryza 


II. Measles. 





Cases to be Readmitted 

Children retiurning after smallpox, scarlet fever, diph- 
theria, measles and chicken-pox must present a 
certificate from the Division of Contagious Diseases 
before readmittance. 

Children returning after mumps and whooping-cough 
may be readmitted at the discretion of the Medical 
Inspector, 

2. Routine Inspection 

At the beginning of each term the Medical Inspector makes a 
routine examination of each child in the schools in his 
charge. The eyelids, throat, skin and hair of each pupil 
are examined. The Inspector is not allowed to touch 
the child, but the latter is required to pull down its own 
eyelids, open its mouth, show its hands, and, in the case 
of girls, lift up her back hair. Individual wooden tongue 
depressors are furnished by the Department. 



Inspection for Detection of Contagious Diseases 37 
INDEX CARD 



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Medical Inspection of Schools 



All cases of disease are recorded on index cards (see p. 37) with 
the proper data in appropriate columns. Code numbers 
are always used to indicate the character of the disease. 

Cases requiring more extended examination are sent to the 
Inspector's room at a definite time for that purpose. 

All cases of contagious disease discovered are dealt with as 
indicated in the description of Morning Inspection. 

All children ordered under treatment are required to report to the 
Medical Inspector, at a definite time, the following morning for re- 
examination. If treatment has been instituted, the fact is recorded 
on the index card, the child ordered to report at regular intervals and, 
as long as treatment is necessary and continued, the child is allowed 
to remain in school. Children showing no evidence of treatment 
are excluded forthwith. 

Each day a record of the number of children examined, with names, 
addresses and cause of exclusion of each excluded child, is mailed to 
the Central Office. A duplicate is kept on file at the school. The 
following is the form of card used for this purpose: 



INSPECTOR'S DAILY REPORT OF EXCLUSIONS 

MEDICAL INSPECTORS OF SCHOOLS ' 

New York, 190..... 



School No. 

Ezamined'lT. .. ^' 
J Koutine .. 



Time of 



) Depa'rture., 





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No. of Vaccinations Performed. P R Total 

No. of Physicals Made No. of Children Found Defective.. 



.Medical Inspector 



Inspection for Detection of Contagious Diseases 39 

3. Absentee Visiting 

The Inspector obtains from the Principal of the school, each 
day, a list of all children who have been absent from 
school for several days for any unassigned cause. These 
children are visited at their homes, and a list of the names, 
ages and addresses of all cases of contagious disease 
discovered is sent, each day, with the school report, 
to the Central Office. 

Large systems obviously require somewhat complicated organiza- 
tions if thorough work is to be done. Efficiency and economy of labor 
demand that printed forms be used wherever their use obviates the 
necessity for any considerable amount of writing, and the same consider- 
ations demand that on these printed forms underlining or checking of 
printed words be used wherever possible instead of filling in of blank 
spaces. There is the greatest variation in the practice of different cities 
as to the amount of printed material used. Brockton, Mass., which 
is a city of over 40,000 population, uses the very simple blanks described 
earlier in the chapter and has only a very few other forms. Providence, 



INSPECTOR'S DAILY REPORT OF EXCLUSIONS, REVERSE 

EXCLUSIONS 



NAME 



AGE 



RESIDENCE 



FLOOR 



ABSENTEES 



REASON 



40 Medical Inspection of Schools 

R. I., has a blank provided for almost every possible need. The follow- 
ing is a list of the printed material furnished by the Providence Board 
of Health as in use in connection with their system of medical inspection: 



PRINTED MATERIAL USED IN CONNECTION WITH MEDICAL 
INSPECTION OF SCHOOLS. PROVIDENCE, R. I. 

Rules for teachers. 

Teacher's note to School Inspector. 

Exclusion card. 

Post card report of case of contagious disease. 

Diagnosis card. 

Post card excluding from Sunday School. 

Permit to attend school while living away from home. 

Permit to return to school. 

Directions for using petroleum — English and Italian. 

Directions for using white salve — English and Italian. 

Directions for using petroleum — English and Yiddish. 

Vaccination notice. 

Post card excluding pupils — diphtheria. 

Post card excluding pupils — measles. 

Post card reporting on diphtheria culture. 

Oculist report. 

Diphtheria exudation report — post card. 

Circular to teachers on referring children to Medical Inspector. 

Circular to teachers on rules for children. 

Rules for each child. 

Notice to parents on eye defects. 

Notice to parents on other defects. 

Notice to principal of families having scarlet fever and diphtheria. 

Circular on above. 

Directions to principals on eye test. 

In pm-suing the ends of efficiency and economy of labor it is not 
sufficient merely to have a blank form for each necessity that may arise. 
The true object is to attain the desired results with the least possible 
amount of clerical work and this is especially true when the clerical 



Inspection for Detection of Contagious Diseases 41 

work is to be performed by a high-priced man, as in the case of the school 
physician. 

Let us consider the case of the school physician who has examined 
a child referred to him and has found him to have unmistakable symp- 
toms of a contagious disease. Some system is necessary by which 
he can so dispose of the case as to notify fully everyone concerned. 
This requires — 

1. An exclusion notice to be sent to the parent. 

2. A record for the school authorities. 

3. A record for the Board of Health. 

4. A record for himself. 

The record for the Board of Health and the exclusion notice require, 
in addition to the name of the child and the disease, the name and 
address of the parent. 

Under many systems these notices are made out on four separate 
cards or sheets, and often the work is still fiurther increased by having 
a separate card for the record of exclusions from each room in the school. 
This makes it necessary to secure the appropriate card before the record 
can be made. Under such conditions the physician spends five or six 
times as much time in making entries on different cards as he does in 
inspecting the child. 

A large part of this waste of time and money can be obviated by a 
carefully planned system of records. In the case in point, for example, 
the work can be greatly reduced by adapting a system similar to the one 
in use in Chicago. Instead of being furnished with supplies of cards 
for making the several records, each inspector is supplied with a book 
similar in size and shape to an ordinary check book. The leaves of 
the book are alternately of light and heavy paper and are perforated 
for separation and have stubs just like the leaves of a check book. The 
thin leaves and stubs are printed as shown on page 42. 

The heavy sheet underneath this is an exact duplicate, except that 
in the lower left-hand corner, instead of the words "Hand to pupil 
excluded" it has the words "Mail this card to Chief Medical Inspector 
same day pupil is excluded." 

When an exclusion case is found, the method of procedure is simple. 
The inspector inserts a piece of carbon paper between the two sheets 



42 



Medical Inspection of Schools 



EXCLUSION NOTICE WITH DETACHABLE STUB. CHICAGO 






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Inspection for Detection of Contagious Diseases 43 

and fills out the blank and its stub. The original blank is the exclusion 
notice and is taken home by the pupil. The stub is handed to the school 
authorities as their record of the case. The carbon copy on the heavy 
sheet is torn out to be sent to the Board of Health as their notification 
of the case and the stub of the carbon copy is left in the book as the 
inspector's record. 

At the conclusion of his work the inspector encloses all of the 
carbon copies of the exclusion notices in an envelope and forwards it to 
the Board of Health. This envelope, besides being the holder for the 
exclusion notices, is the daily report of the inspector. On its face are 
blanks to be filled out as follows: 



ENVELOPE DAILY REPORT OF MEDICAL INSPECTOR IN 

WHICH ARE FORWARDED TO BOARD OF HEALTH 

COPIES OF EXCLUSION NOTICES. CHICAGO 

CITY OF CHICAGO, DEPARTMENT OF HEALTH 



MEDICAL INSPECTION OF SCHOOLS 
Inspector's DAILY Report of Number of Examinations and Exclusions 

I have this day examined pupils at the 

(number) 

School, made cultures for bacterial exam- 

(ntjmber) 

ination, performed vaccinations, and excluded pupils from 

(number) (number) 

attendance at school for reasons stated on the enclosed exclusion cards. 

Date, 19 M.D. 

MEDICAL INSPECTOR 

(Place the Exclusion Cards in this holder, enclose whole in special envelope and mail to Chief 
Medical Inspector. Report must be made EVERY SCHOOLDAY, whether inspection has or has 
not been made.) 



The saving effected by means of such a system as this is plainly 
seen by comparing the number of entries necessary under the separate 
card method with the number required by the " check-book and carbon 
copy" method. 



44 Medical Inspection of Schools 

ENTRIES NECESSARY BY THE CHICAGO METHOD AND 
THE CARD METHOD 

Chicago Method. Separate Card Method. 

1. Notice and Stub. i. Notice to Parents. 

2. Envelope Daily Report. 2. Record for school. 

3 . Record for Board of Health. 

4. Record for Inspector. 

5. Daily Report. 

This system has been described at length because the principle 
underlying it is fundamental. If medical inspectors are to do eflBicient 
work, they must not be over-burdened with complex clerical work. 
The aim in every case must be the smallest possible number of original 
entries. 

One commendable time-saving device which has been adopted in 
some cities is that of having the different cards used of different colors 
so that the medical inspector can put his hand on the card he wants 
without a moment's delay. Utica and Syracuse, N. Y., have adopted 
this plan. Thus, in Utica the physical record card is white; the notice 
to parents of physical defects, salmon colored; the exclusion card, buff; 
the card of directions for ridding the hair of vermin, pink; and the card 
for the same purpose but with the directions printed in Italian is cherry 
color. The room record of pupils excluded and re-admitted is lavender. 

In a number of cities it has been found necessary to print some of 
the cards which go to parents in several foreign languages. 

There is only one feature which all American systems of medical 
inspection have in common. This is the supplying of printed directions 
in some form for ridding the hair of vermin. Quite the best of these 
plans seems to be that followed in Everett, Mass., where the pupil 
is not only given directions as to the treatment, but is furnishied with a 
druggist's prescription for the materials required. Everett applies 
this idea not only in the case of pediculosis (lice), but also for the other 
common complaints of impetigo contagiosa, ringworm and scabies. 
The forms used are reproduced on pages 45 and 46. 

In nearly all systems there are furnished to the medical inspectors 
printed regulations and instructions. While there is considerable 



COMBINED DIRECTIONS AND PRESCRIPTION. EVERETT, 

MASS. 



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Inspection for Detection of Contagious Diseases 47 

variation as to detail, these are in the main similar in intent and provi- 
sions. They all provide that the inspectors shall examine pupils referred 
to him by the teachers. Some of them require in addition that at stated 
intervals the inspector shall make a routine examination of all the pupils. 
In some places this is done once in two weeks, in others once a month 
or once a term. In nearly all systems the inspectors are required 
to examine pupils who have returned to school after several days of 
unexplained absence. In most places there is a provision in the 
regulations to the effect that the physician shall not himself prescribe 
for any pupil, unless regvdarly called to do so by the parents. 

There is considerable variation as to the diseases considered "ex- 
cludable." In many places the rule is simply to exclude all cases of 
communicable disease. In other places specific lists are given. Some 
of these are given on page 48. 

Where school nurses are employed it is found that the number 
of exclusions can be greatly reduced by treating many of the minor 
contagious ailments at the school. 

It is almost impossible to get any reliable statistics as to the number 
of cases of contagious diseases found in different localities. Diligent 
examination of all of the printed reports obtainable from cities having 
systems of medical inspection yields very meagre results. In most 
cases the doctor's report shows how many cases of contagious disease 
were fotmd, but not how many children were examined in finding the 
cases. Again, when the number of children examined is stated it is 
almost always found on investigation that the number given represents 
not the number of children examined but the number of examinations 
of children. Thus the boy who is examined ten times is counted as ten 
children. In this way the Board of Health of New York City reported 
12,236,050 children examined in 1904, when the average attendance 
in all the public schools was only 487,000. One of the crying needs 
of medical inspection is the development for it of a rational system of 
statistics. 



48 



Medical Inspection of Schools 



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Inspection for Detection of Contagious Diseases 49 

After much labor the following brief figures as to exclusions in five 
cities in 1907 have been gathered: 

EXAMINATIONS AND EXCLUSIONS IN FIVE CITIES 

Number Number Per Cent, of Those 

Examined. Excluded. Examined, Excluded. 

Brockton, Mass. (3 months) 3,208 347 10.8 

Lawrence, Mass. (3 months) 1,424 139 9.8 

Montclair, N. J 2,503* 242 9.7 

Newark, N. J 21,299 2323 10.9 

Springfield, Mass 8,759 ^°43 12.2 

About the only conclusion to be drawn from this table is that under 
common practice in cities not employing school nurses about 10 per 
cent, of the children referred to the school physician will be found to be 
suffering from diseases serious enough in nature to warrant their exclu- 
sion. 

In Massachusetts schools of the State having an average member- 
ship of 343,000 reported during the school year 1906-07 children 
suffering from diseases or defects as follows : 

DISEASES AND DEFECTS REPORTED IN MASSACHUSETTS, 

1906-07 

Diphtheria 238 

Scariet fever 313 

Measles 637 

Whooping-cough 973 

Mumps 367 

Chicken-pox 548 

Influenza 276 

Syphilis 36 

Tuberculosis 115 

Erysipelas 17 

Adenoids 2,525 

Other diseases of the oral and respiratory tract 5,103 

Otitis 407 

Other diseases of the ear 363 

Conjunctivitis 779 

Other diseases of the eye 2,159 

Scabies i ,054 

Pediculosis 7,691 

Impetigo contagiosa 1,568 

Ringworm 715 

Other diseases of the skin 1,170 

Chorea 105 

Epilepsy 41 

Deformities (spinal and extremities) 142 

Total of diseases and defects 2 7,342 

* Average attendance. 



50 Medical Inspection of Schools 

Of course defects of vision and hearing are not included in the above 
table. However, even these incomplete figures show that the aggre- 
gate effect upon school attendance and school work is a subject for the 
most serious thought. 

That the whole matter of the relation of contagious diseases to the 
school life of children is one for serious thought has been convincingly 
demonstrated. There is a mass of evidence showing conclusively 
that the schools are a principal means of disseminating disease through- 
out the community. This evidence can be readily secured by any one. 
Pupils are very apt to attend schools during the earlier stages of diph- 
theria and during the late but peculiarly infectious stage of scarlet 
fever, thus spreading the disease throughout the community. Medical 
inspection greatly reduces this danger. It is the testimony of Dr. 
Samuel H. Durgin, Chairman of the Boston Board of Health, that since 
the system of the medical inspection of schools was introduced in Boston, 
diphtheria has fallen off about two-thirds and scarlet fever about five- 
sixths. In the case of diphtheria, antitoxin has of course played a 
leading part. In the case of scarlet fever the starting of the new infec- 
tious ward at the City Hospital has had an important effect. But 
in both cases, medical inspection in the schools has also been impor- 
tant, as shown by the fact that before the inspection began some diseases, 
such as diphtheria, for instance, were more common during the school 
term than during the vacation period, but that after the inspection 
was introduced, they were less common diuring the school term than 
during vacation. 

Again, extensive studies indicate that over 90 per cent, of the deaths 
from contagious diseases, such as diphtheria, scarlet fever, whooping- 
cough and measles, occur before the age of ten. 

Contrary to popular opinion, there is great mortality from measles 
when this occurs in the early stages of life, and among the children of 
the poorer classes. Extensive statistics collected in the city of Munich 
show that the mortality from this disease between the second and 
fifth year was 4.55 per cent., while from the sixth to the tenth year it 
was only .4 per cent. These figures would indicate that if an epidemic 
occurs in the kindergarten period the deaths are likely to be 45 in 
1000, whereas if the epidemic can be postponed until the primary 
school period, only 4 in 1000 will die. 



Inspection for Detection of Contagious Diseases 51 

In the face of such evidence as the above to argue for medical in- 
spection is to argue for the promotion of efficiency in our schools, the 
protection of the community and the preservation of the lives of its 
children. 



CHAPTER V 

The Work of the Teacher in Detecting Con- 
tagious Diseases 

There is considerable difference of opinion among physicians hav- 
ing charge of systems of medical inspection as to whether the medical 
inspector should visit the school room only when called on by the principal 
or teacher, or whether he himself should systematically inspect without 
such call. As the result of the non-agreement upon this point there is, 
of coiu"se, wide variation in practice in different localities. 

Expressed in its simplest terms, the problem really resolves itself 
into the question, — Is or is not the room teacher competent to detect 
symptoms of disease among her pupils ? 

Among the important opinions which may be cited in support of 
the contention that the room teacher is competent to detect such symp- 
toms are those of Dr. C. Koon, of Grand Rapids, Mich., Dr. Bert Not- 
tingham, of Lansing, Mich., and Superintendent of Schools E. C. 
Moore, of Los Angeles, Cal. 

Dr. Koon, in speaking of the Grand Rapids system, says: 

"We place the responsibility of sending pupils for 
inspection on the teachers. It is impossible to have 600 
or more pupils examined every morning. It would dis- 
commode school work. We have the same rule as in 
Detroit. The teachers in each room simply ask if any 
pupils are feeling sick, and if so, they are sent to the 
principal's room. If any child is out of school for the day 
that child is sent to the principal's room and examined. 
That is the better way. The teacher knows all her pupils 
and knows easily whether any pupil is feeling sick by his 
actions." 

52 



Work of Teacher in Detecting Contagious Diseases 53 

In speaking of the Lansing system, Dr. Bert Nottingham says: 

"The system is a combination of the Ann Arbor and 
Detroit systems. The teachers detect the cases of disease. 
We hold classes of instruction with teachers and show 
them how to detect these diseases. We have a specialist 
on eye, ear, nose and throat, who gives them information 
about detecting weaknesses. Also we have the specialist 
on eye, ear, nose and throat as one of the inspectors." 

In a similar tone. Superintendent E. C. Moore, of Los Angeles, 
Cal., says: 

"The best health officer is one who is present all the 
time and ever watchful for the welfare of the child. That 
ever-present health officer is the teacher." 

On the negative side of the question may be cited Dr. Thomas F. 
Harrington, Director of School Hygiene of Boston, and Dr. Elliott 
Kent Herdman, Medical Inspector of Schools, Ann Arbor, Mich. 
In an address delivered before the national meeting of the Department 
of Superintendence of the National Education Association, held at 
Washington, D. C, February 25-27, 1908, Dr. Harrington expressed 
the following opinion : 

" An important fact in the method of medical inspection 
under the Board of Health is that the detection of cases of 
contagious diseases among the children is done by the 
teacher and not by the medical inspector; if the latter con- 
firms the suspicion of the teacher, the child is excluded from 
school; if the inspector does not agree with the conclusions 
of the teacher, the child returns to his classroom. Non- 
agreement is very frequent, and it requires exceptional 
perseverance for a teacher to hazard the chagrin of a 
second mistake, yet disastrous consequences might result 
from such hesitation. In Boston diu-ing the year 1905, 
21,111 children were referred to the medical inspectors; 
9,241 were found free from any disease. In London 



54 Medical Inspection of Schools 

between 20 and 30 per cent, of the cases submitted by 
the teachers were not suffering in any way." 

In a paper read before the Ninth General Conference of Health 
Officers in Michigan, Dr. Herdman said: 

"In some cities the inspectors are required merely to 
take the daily reports of the various teachers. I am 
satisfied from my own experience that this is not enough. 
A school teacher, however excellent, is no more able to 
detect disease in the school room than in the home, and 
detection is all important." 

" I go into the schoolroom and sit down to familiarize 
myself with the faces of the pupils. After a few times, 
they have become used to it and I can detect anything 
wrong, I think the doctor should go into the schoolroom 
at least once a week. The teachers simply cannot detect." 

Despite the radically contradictory nature of these opinions, the 
problem has been solved satisfactorily in many localities. The solu- 
tions are in the nature of compromises between the system of relying 
entirely on the teacher for detecting symptoms of disease and that of 
insisting that the doctor alone shall make the inspection. 

It is the verdict of experience that three general propositions hold 
true: First, it is impracticable to have the doctor inspect all the children 
every day. Second, he should see them all sometimes. In some 
systems such routine inspections of all pupils are made once in two 
weeks, in others once a month, and in still others once a term. Third, 
where school nurses are employed the problem largely disappears, 
as the teacher and the nurse together readily decide which pupils should 
go to the inspector. 

In localities where systems have been carefully worked out, teachers 
are provided with printed directions as to the symptoms which they 
should notice and on account of which children should be referred to 
the school physicians. Probably the most carefully worked out set 
of such instructions is that given in the pamphlet issued by the Mass- 
achusetts State Board of Education, containing suggestions of teachers 



Work of Teacher in Detecting Contagious Diseases 55 

and school physicians regarding medical inspection. This little book 
so well fills the need that it has been reprinted for use in many other 
localities. It is such a good example of what such a manual should be 
that it has seemed well to reprint it in its entirety in this volume. It will 
be found as Appendix I. Under the heading, " Some General Symptoms 
of Disease in Children which Teachers should Notice, and on Account 
of which the Children should be Referred to School Physician," it 
gives explanatory directions under each of the following headings : 

Emaciation, 

Pallor, 

Puffin ess of the face, 

Shortness of breath, 

Swellings in the neck. 

General lassitude and other evidences of sickness, 

Flushing of the face. 

Eruptions of any sort. 

Cold in the head with running eyes, 

Irritating discharge from the nose, 

Evidence of a sore throat. 

Coughs, 

Vomiting, 

Frequent requests to go out. 

In the Annual Report of the Superintendent of Schools of Albany 
for 1907 is found a list of symptoms for which teachers are required 
to refer children to the inspector. The list is not very different from 
that used in Massachusetts. It is as follows: 

ALBANY LIST 

Unusual pallor. 

Unusual dullness or sleepiness. 

Red or discharging eyes, 

Reddened or discharging ears, 

Deafness, 

Discharge from the nose, 

Mouth-breathing, 

Enlarged glands in the neck, 



56 Medical Inspection of Schools 

Swelling of neck at angle of jaw, 

All skin eruptions, 

Constant scratching of any part of the body, 

Children who maintain peculiar postures at the desk. 

Children showing defective vision of either or both eyes. 

Children returning to school with excuse alleging illness and 

without note from attending physician, 
Children returning to school or attending regularly and living 

at the same time in houses in which there is, or has recently 

been, illness, 
Children asking frequent permission to go to the toilet. 

Providence, R. I., Syracuse and White Plains, N. Y., also furnish 
the teachers with similar printed directions. Providence, however, 
goes farther than this. There each teacher is furnished with a slip of 
paper to be pasted in her roUbook, where it will always serve for ready 
reference and as a constant reminder. This slip contains the following 
rules : 



RULES FOR CONTAGIOUS DISEASES, PROVIDENCE, R. I. 
RULES FOR CONTAGIOUS DISEASES. 



The Teacher will please paste this in the register book. 



Children with the following diseases must be kept out of School: 

With chicken-pox until the crusts are all off. 
With mumps two weeks, and longer if the glands are tender. 
With whooping cough while the child whoops. 
With German measles for two weeks. 

With measles until two weeks from the beginning of the 
sickness. 

When there is measles in a farnily, children who have previously 
had it may be allowed in school. Those who have not had it must be 
excluded for two weeks from the beginning of the last case. 

Permits are not necessary for any of the above. The teacher can 
usually determine the duration of the sickness better than the medical 
inspector. 

All children living in houses where there is diphtheria, scarlet 
fever or small-pox must be excluded from school until they present a 
permit from the health department. 



Work of Teacher in Detecting Contagious Diseases 57 

Moreover, each teacher is furnished with a supply of sheets of 
paper on which are printed in simple language rules to be observed 
by the pupils and which the teacher is expected to teach and enforce. 
A copy is given to each child. 

PRINTED RULES DISTRIBUTED TO ALL PUPILS 
IN PROVIDENCE, R. I. 

REMEMBER THESE THINGS. 

Do not spit if] you can help it. Never spit on a slate, floor, or 
sidewalk. 

Do not put the fingers into the mouth. 

Do not pick the nose or wipe the nose on the hand or sleeve. 

Do not wet the finger in the mouth when turning the leaves of books. 

Do not put pencils into the mouth or wet them with the lips. 

Do not put money into the mouth. 

Do not put pins into the mouth. 

Do not put anything into the mouth except food and drink. 

Do not swap apple cores, candy, chewing gum, half eaten food, 
whistles or bean blowers or anything that is put in the mouth. 

Never cough or sneeze in a person's face. Turn your face to one 
side. 

Keep your face and hands clean; wash the hands with soap and 
water before each meal. 

Another feature of the Providence system is that the principals 
are furnished by the Department of Health with printed lists of the 
famihes of the city in which scarlet fever or diphtheria has been reported, 
to the end that children living at locations named on the list may be 
excluded from school until permits for their return are furnished by the 
department. 

The city of Wilkesbarre, Pa., goes even farther than does Provi- 
dence, R. I., in the matter of giving each pupil a set of simple health 
rules. The scheme is rather novel. The school board has adopted 
six simple rules for promoting health. They are to be printed on the 
cover of every book used in the public schools. Here they are: 



58 Medical Inspection of Schools 

1. Fresh air and sunshine are necessary to good health. 

2. Night air is as good as day air, and in cities where there is much 

dust, better. 

3. Eat little fried food, pastry, candy, cake, and sugar. 

4. Wash your hands before you eat. 

5. Never lick your fingers when turning pages or when counting 

money. 

6. Avoid spitting because it promotes consumption and other 

diseases. 

There are several plans by which the teacher refers to the school 
physician the children she believes to show symptoms of some illness. 
The simplest and perhaps the most common is for the teacher to send 
the children to the principal's or the school physician's room without 
any note as to what trouble she suspects or any particulars as to the 
case. There are good reasons why this system is not satisfactory. Some 
of them are well stated by Dr. S. W. Newmayer, of Philadelphia, in 
"A Practical System of Medical Inspection with Trained Nurses, 
Adapted for Public Schools of Large Cities." Dr. Newmayer says: 

"Each morning the teacher fills out for each pupil she 
desires examined by the inspector that part of the card 
above the dotted line. This may seem as though more 
clerical work is being shifted on the aheady overworked 
teacher. But a moment's reflection will prove it saves her 
time, trouble, and responsibility. Many of the younger 
pupils do not know their name, address, and number of 
classroom, much less why the teacher sent them to the 
doctor. This necessitates the return of the pupil to his 
class with a note requesting the desired information, 
:' which is eventually written on any scrap of paper, to again 

be copied by the doctor, and a third time by the nurse. 
I have heard teachers say, ' Who wishes to go to the doctor ? ' 
There are a few shiftless pupils who are only too ready 
to accept such an invitation to get out of the classroom. 
With the teacher answering the question, 'Why sent to 
medical inspector?' this imposition is avoided." 



Work of Teacher in Detecting Contagious Diseases 59 

A good specimen of a very simple card from the teacher, requesting 
the inspector to examine a child, is that used in the Providence, R.I., 
schools. 

TEACHER'S REQUEST TO INSPECTOR, PROVIDENCE, R. I. 

Note to School Inspector. 

Name 

Residence 

School 

Please examine this pupil jar 

Teacher. 

When out of Blanks notify Health Department. 

A card providing for a fuller statement, and in many ways a better 
one, is in use in the schools of Asbury Park, N. J. It is a standard 
4x6 inch filing card and has the advantage of insuring futiu-e ready 
reference when filed in a card index drawer. 



CARD OF REQUEST TO INSPECTOR, ASBURY PARK, N. J. 
ASBURY PARK PUBLIC SCHOOLS. 

DEPARTMENT OF MEDICAL INSPECTION. 






. 


nntft 


This card is to be ii 
when any pupil appe 
should then be sent 


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6o Medical Inspection of Schools 

REQUEST OF TEACHER AND STATEMENT BY INSPECTOR, 
WASHINGTON, D. C. 

FORM A. 

ORIGINAL. 

HEALTH DEPARTMENT. 
MEDICAL INSPECTION OF PUBLIC SCHOOLS. 

Hour * Date 190 . 

School Building. Room No 

REQUEST FOR MEDICAL INSPECTION. 

Will the Medical Inspector please examine 

, residing at 

to determine the advisability (i) * of exclusion on account of contagious 
disease; (2) * of exclusion on account of non-contagious disease; 
(3) * of readmission. 



Signature of Teacher. 

* When inserting hour, state whether "a. m." or "p. m." 

* Check whichever phrase indicates the purpose of the proposed inspection. 



RESULT OF INSPECTION. 

Date of inspection ,190 . Hour. 

Tentative diagnosis 

* Recommendations 



Signature of Medical Inspector. 

_ *If exclusion is recommended, specify the section of the regulations under which such 
action is to be taken. If duration of proposed exclusion is not determined by these regulations, 
specify the duration thereof. 



Work of Teacher in Detecting Contagious Diseases 6i 



FORM A. 

DUPLICATE. 

HEALTH DEPARTMENT. 
MEDICAL INSPECTION OF PUBLIC SCHOOLS. 

Hour * Date 190 . 

School Building. Room No 

REQUEST FOR MEDICAL INSPECTION. 

Will the Medical Inspector please examine 

, residing at 

to determine the advisability (i) * of exclusion on account of contagious 
disease; (2) * of exclusion on account of non-contagious disease; 
(3) * of readmission. 



Signature of Teacher. 



* When inserting hour, state whether "a. m." or "p. m." 

* Check whichever phrase indicates the purpose of the proposed inspection. 



RESULT OF INSPECTION. 

Date of inspection , igo . Hour. 

Tentative diagnosis 

* Recommendations 



Signature of Medical Inspector. 

* If exclusion is recommended, specify the section of the regulations under which such 
action is to be taken. If duration of proposed exclusion is not determined by these regulations, 
specify the duration thereof. 



62 Medical Inspection of Schools 

A third card of notification is a slip having space provided for the 
teacher's statement regarding the child and the physician's diagnosis 
and disposition of the case. Such a slip is in use in the schools of 
Somerville, Mass. 



STATEMENTS OF PHYSICIAN AND TEACHER, 
SOMERVILLE, MASS. 

No. s) 

190. 

KEEP ON FILE 



TEACHER'S STATEMENT 

{Name) Room No 

School 

Complaint 

PHYSICIAN'S STATEMENT 

Diagnosis 

Advice 



The same plan is followed in Washington, D. C, but with a some- 
what more complex blank and one possessing the additional feature 
of being so made as to provide for filling out at the same time an original 
and a duplicate copy. With this plan, one copy can be kept on file 
in the school and the other sent to the office of the Health Department; 
or one copy can be kept by the school physician and the other by the 
room teacher. 



Work of Teacher in Detecting Contagious Diseases 63 

There are points in favor of each one of the systems described. 
A plan which unites in one simple system the greatest number of these 
points is that described by Dr. Newmayer in the paper above referred 
to. He advocates the use of a card of which the following is a repro- 
duction. 



CARD USED BY DR. NEWMAYER IN PHILADELPHIA, PA. 



School Teacher Room No 

Name Address 

Date Sent to Medical Insp. for 

Diagnosis 

Referred to physician — Dispensary — Nurse. 

Excluded — date Returned 

Treatment by nurse — at home — at school. 
Dates of treatment — 
Results — Cvired 

Improved 
Not improved 

Medical Inspector. 
Total number treatments — 

Nurse. 



The system is devised for use in localities where trained nurses are 
employed and is based on using but one card and one blank. Each 
morning before beginning the day's exercises each teacher goes through 
her class and notes the pupils she wishes to send to the principal. Each 
child is given one of the cards on which the teacher has filled in the three 
lines at the top, giving the school, the name of the teacher, the number 
of the room, the name and address of the child, the date, and the teacher's 
reason for sending the child to the inspector. On these cards the in- 
spector underscores whether the pupil is to go to the nurse, dispensary, 
or family physician for treatment; or whether excluded from the class. 
Each pupil sent to the inspector for examination receives one of the 
following slips to take back to his teacher: 



64 Medical Inspection of Schools 



To Teacher: — 

This child is referred for treatment to 

NURSE 
DISPENSARY 
FAMILY PHYSICIAN 

This child is excluded from the classroom 

until you receive notice for his (her) return. 

Medical Inspector. 



This admits of no mistake by the teacher and aids her in knowing 
the exact nature and disposition of each case. The child cannot go 
home for the remainder of the day if he has been instructed to wait 
for treatment by the nurse, and, again, a child excluded cannot return 
to his seat in the classroom and the teacher remain ignorant of his 
exclusion by the inspector. It admits of the principal having a full, 
written record of the disposition of all cases sent to the inspector. 

When the case is referred to the nurse, the inspector specifies on 
the card if the child is to be treated at home or at school, or both; also 
the treatments recommended. This concise written report makes 
mistakes impossible and may prove valuable if legal or other questions 
arise. 

These cards are filed in the office in a box with three compartments : 
first, "New cases"; second, "Unfinished cases"; third, "Cured cases." 
Each of these compartments is arranged according to the number of 
classrooms. Dr. Newmayer states : 

" The nurse, on visiting the school, first takes all cards in 
the compartment of new cases, and sends for each pupil 
individually. The information on the card makes it 
possible for her to perform all her work without troubling 
the principal or teachers. After attending to the new 
cases and recording on them the date of treatment, she 
replaces them in the cabinet, in the compartments of un- 
finished or ciued cases. She now looks over the unfinished 
cases and sends for those requiring treatment, again re- 



Work of Teacher in Detecting Contagious Diseases 65 

cording the date. She so proceeds each day until the 
child is cured or disposed of, when she records the date 
of cure, when the card is filed in the third compartment. 
Once a month all finished cards are sent to the Bureau 
of Health or Bureau of Education, where they are filed in a 
cabinet according to school and disease. One can readily 
see how easy it would be to refer to these records. For 
example, should one desire to know how many cases of 
defective vision were treated and obtained the necessary 
glasses, or the average number of treatments required 
at school to cure a certain skin disease, these facts can 
readily be obtained." 

Each week the nurse makes out a report of her work, which is 
forwarded to the chief medical inspector. A reproduction of the 
blank used will be found on page 78 in the chapter, "The School 
Nurse." It is, of course, evident that the system described, using only 
one card and having a slip returned to the teacher, telling what disposi- 
tion the school physician has made of the case, is just as applicable 
to systems where nurses are not employed. 

From the viewpoint of efficiency it is a much mooted question whether 
teachers should or should not have the duty of attempting to detect 
signs of ilhiess among the children. In established systems this question 
is a very real problem of administration and is probably best solved 
by such a compromise as was described earlier in this chapter. In 
places where systems of medical inspection do not exist and where 
their establishment depends on making a simple and inexpensive begin- 
ning the problem disappears. Conditions inevitably resulting in disaster 
to the physical well-being of the pupils exist in our schools as a con- 
sequence of grouping together children from all sorts of homes, from 
families of all sorts of standards of cleanliness and health. Under 
these circumstances the important thing is to construct the social ma- 
chinery to deal with the problem that confronts us. The teacher, being 
present, available, and in direct contact with the children, is the one 
to whom we must look as the agency for the initial starting of the 
machinery. 



CHAPTER VI 

The School Nurse 

Dr. S. W. Newmayer, of Philadelphia, terms the school nurse "the 
most important adjunct to medical inspection." Dr. John J. Cronin, 
of New York, in writing of the work of the school nurse in that city, 
says: "Instead of opposition to this work at school, it is most highly 
endorsed by teachers, principals, educators, parents, and children. 
Since this innovation many cities throughout the world have copied 
our niursing system as far as possible, up to the standard set by this 
city." Dr. Ernest J. Lederle, formerly Commissioner of Health of 
New York City, says, "The school nurse has been voted a success 
from the day she began work." Dr. Walter S. Cornell says of the school 
nurses in Philadelphia, "As a rule, in the foreign, poverty-stricken 
sections they are invaluable." Dr. Thomas F. Harrington, Director 
of the Department of School Hygiene of Boston, writes, " It does not 
seem possible to conceive a more satisfactory arrangement or a more 
effective piece of school machinery than the school niu-se under school 
supervision." 
• Citations from the best authorities on the subject, similar in tone 
to those quoted, might be indefinitely multiphed. It may be said indeed 
that there is no division of opinion on the subject. The leading authori- 
ties without exception advise and recommend school nurses in con- 
nection with the work of medical inspection. 

Although this feature of the work is recognized as being so im- 
portant, its development in America has been comparatively recent. 
The first regular employment of trained nurses in connection with the 
work of medical inspection seems to have been in December, 1902, 
in New York City, when a corps of nurses was established at a salary 
of $75.00 each per month. Previous to this the experiment had been 
tried in a small way, but with great success, in London. The success 
of the experiment was immediate and the movement has spread rapidly. 

66 



The School Nurse 67 

New York still maintains the corps of trained nurses. Philadelphia 
and Boston have them. Baltimore, Los Angeles, Grand Rapids, 
New Haven, Orange, N. J., and Syracuse and Yonkers, N. Y., are 
among the other cities employing school nurses. 

Indeed, experience has proved — especially in the largest cities, where 
systems of medical inspection have been in operation some time — that 
the employment of competent school nurses is almost a necessity. This 
comes to light first in dealing with the cases of children who have been 
excluded for minor contagious diseases. A child who has been sent 
home, say for pediculosis, receives no attention from his parents. After 
a few days' absence he returns to school in the same condition in which 
he left. This process may be repeated several times before the child is 
finally put into fit condition for resuming his school work. The result 
is that when he does return, he is behind in his studies; and while he 
has been absent, the city has been paying for his instruction and no 
instruction has been received. Such cases as this are typical and numer- 
ous. Again, there are many simple cases of minor ailments which, 
properly treated by the nurse in school, will not prevent the regular 
attendance of the child. Where such treatment is not possible, they 
compel his temporary exclusion. In many other cases the school 
nurse, by visiting the home and conferring with the parents, secures 
treatment of some ailment by the family physician which in the absence 
of such home visiting would be neglected. 

Such considerations as this played a large part in bringing about 
the establishment of the first regular corps of trained nurses for work 
in the public schools. As before stated, this was in New York in 1902. 
Previous to that time there had been a system of medical inspection 
in operation for some eight years. Before the nurse began work it was 
found that many of the children that were excluded on account of 
contagious diseases received no home care whatever. The parents 
either failed to understand the printed card, or ignored it altogether. 
The child, instead of being attended to, was left to play in the street, 
and associated with the other children as they came out of school, 
thereby coming in contact with them almost as much as if he had re- 
mained in school. Contagion was not being greatly lessened in the com- 
munity; the child was not receiving medical attention, but was losing his 
schooling. 



68 Medical Inspection of Schools 

That the employment of competent school nurses very greatly reduces 
the number of exclusions from school was conclusively proved by the 
experience in New York before and after their employment. For 
the quarter ending December, 1902, we have the following table of 
exclusions from the New York public schools: 

Measles 18 

Diphtheria 140 

Scarlet Fever 13 

Whooping Cough 61 

Mumps 9 

Trachoma 12,647 

Pediculosis 8,994 

Chicken-pox 172 

Skin Diseases 661 

Miscellaneous i ,823 

Total 24,538 

During this time there were sixteen diseases which were excluded. 
The corps of nurses was organized in December. A card index system 
was installed by which an absolute record of every case of contagious 
diseases in the schools could be kept, together with the dates of treat- 
ment and termination. Under this system the number of excludable 
diseases was limited to seven. These when found must be excluded 
at once. They are: 

Diphtheria Pertussis 

Scarlet Fever Mumps 

Measles Acute Coryza 
Varicella 

It will be readily seen that had this system been in use during the quarter 
ending December 31, 1902, there would have been the following ex- 
clusions only: 

Measles 18 

Diphtheria 140 

Scarlet Fever 61 

Mumps 9 

Chicken-pox 172 ^ 

Total 460 



The School Nurse 69 

In other words, the number of exclusions under the old system of 
medical inspection, without the careful card record and trained nurses, 
was 24,538. After the installation of the card system and the employ- 
ment of the nurses, this number would have been reduced to 400. 
The difference, representing the number of pupils who, although suf- 
fering from some minor contagious ailment, are allowed under the new 
system to continue in school, is 24,138. In addition it has been found 
necessary to add to this list cases of pediculosis, with live pediculi, 
and contagious skin diseases where the pupil has persistently refused 
to undergo treatment. While these additions reduce to some extent 
the proportion of those who are allowed to continue in school, it still 
remains true that the number of exclusions since the installation of the 
card system and the employment of the nurses has been immensely 
reduced. 

A good idea of what may be accomplished by the trained nurse 
in the public schools is given by Dr. S. W. Newmayer, of Philadelphia, 
in a paper read at a meeting of the Medical Society of Pennsylvania, 
September 11-13, 1906. He describes the work of one nurse, Miss 
Annie L. Stanley, who was loaned to the city of Philadelphia by the 
Visiting Nurse Society to show the great value of the trained nurse in 
the medical inspection of schools. 

In April, 1904, the schools of the Fourth Section, five in number, 
were assigned to the nurse. A well-organized system was worked 
out and closely followed. The nurse visited the schools daily, three 
in the morning session and two in the afternoon. The medical inspec- 
tor diagnosed and excluded from the school cases of contagion and 
recommended for treatment children suffering from various ailments. 
Written instructions as to the disposal of each case, treatment recom- 
mended, and whether the case was to be visited by the nurse at its 
home, were left at the office of the principal. The nurse each day 
obtained from this office the instructions. She followed up each case 
and saw that the instructions and recommendations of the physician 
were brought to a speedy and successful termination. In each school 
a small room was set aside for the work of the nurses. Here she had a 
drug closet and all requisite supplies. When necessary, she visited 
the homes of the children to give treatment and instructions, and ob- 
tained the cooperation of parents, thereby assuring success and more 



70 Medical Inspection of Schools 

permanent results. Sometimes circumstances made it necessary for 
the nurse to personally take a child to the dispensary for treatment. 
These home and dispensary visits were made after school hours and 
on Saturdays. There were various problems to be solved in each 
case, and the nurse invariably found the remedy. The duties of the 
school nurse assvired success to the work of the medical inspector in 
improving the health of the school children. She lessened the number 
of exclusions from the classroom for minor contagious diseases. She 
saw that all excluded cases were placed under treatment as soon as 
possible, so that there should be the least possible loss of time from 
school and education. She treated those cases which would for various 
reasons receive no attention at their homes. The medical inspector 
recognized and excluded from the school cases of contagion, and recom- 
mended for treatment children suffering from defects hindering them in 
their studies. These cases might or might not receive the necessary 
attention, but with the nurse all uncertainty was dispelled. 

It was also found feasible to use the nurse during the summer 
months when there was no school, in the lessening of the great mortality 
rate among infants from summer diarrhea, due mainly to improper 
care and feeding. Again, she aided materially in the campaign to lessen 
the number of cases and spread of consumption. 

The following is a report of the work of the trained nurse in the 
schools of the Fourth Section: 



WORK OF THE TRAmED NURSE IN THE SCHOOLS OF 
THE FOURTH SECTION, PHILADELPHIA 

From Sept., 1905, to June, 1906 

Schools visited 5 

Scholars in attendance 4800 

Visits to schools 656 

Old cases treated 3863 

New cases treated 907 

Total number of cases 477° 

Cases cured 781 

Taken to dispensaries 49 

Visits to dispensaries 97 

Cases treated at home 342 

Visits to homes S33 



The School Nurse 71 



Cases Treated at School 

Pediculosis 249 

Impetigo 98 

Ringworm of body 30 

Ringworm of head 6 

Eczema 85 

Conjunctivitis 126 

Stye 4 

Favus 2 

Pustular dermatitis 15 

Infected wounds, contusions, etc 113 

Miscellaneous 55 

Defective vision; glasses furnished 124 



NURSE'S VISITS TO HOMES 

From Sept., 1905 to June, 1906 
Disease No. of No. of No. Cured 

Cases Visits 

Defective vision 138 172 124 procured glasses 

Scabies 8 25 8 

Favus 2 19 2 

Acute conjunctivitis 5 30 4 

Discharging ear 4 7 4 

Not vaccinated 12 12 12 

Pediculosis 121 143 78 

Pustular dermatitis 14 25 14 

Uncleanliness 19 27 19 

Congenital deformity i 3 Admitted to Widener 

Memorial Home 

Ringworm 5 29 5 

Improperly nourished 13 22 Proper nourishment 

obtained 

Children Taken to Dispensaries 

Disease No. of No. of 

Cases Visits 

Defective vision 41 63 

Favus 2 7 

Acute conjunctivitis 3 14 

Scabies 3 13 

In explanation of the above report of the trained nurse, Dr. New- 
mayer submits the following: 

"The percentage of pediculosis existing in these schools 
when the nurse began work in April, 1904, was thirty 



72 Medical Inspection of Schools 

per cent. This has since been reduced to eight per cent. 
Most of these cases were absolute cures, as the disease 
has not recurred in the same scholars. This is mainly- 
due to the influence at the homes by the nurse. There 
remain very few cases of ringworm and impetigo, which 
at first were prevalent in large numbers. Conjunctivitis 
and corneal ulcers received no attention from the parents, 
and were treated only after the children were taken in 
charge by the nurse. They were soon cured and the 
children able to resume their studies. These cases in- 
cluded several in which corneal ulcer threatened the 
sight. Weak, anemic children, unable to work or study, 
due to impoverishment from improper food, were visited 
in their homes, and the existing difficulties, whether ex- 
treme poverty, sick or drunken parents, corrected. Over 
two hundred children with bad, defective vision were 
treated and supplied with necessary glasses only through 
much persuasion and the most persistent efforts of the 
nurse. This often required many visits to the homes." 

Wherever they are employed, the home visiting by the school nurses 
is recognized as one of the most important, if not the most important, 
feature of the whole system. Dr. H. W. Buckler, one of the medical 
inspectors of Baltimore, says that this featiire of the work is the most 
efficacious in its direct results and the most far-reaching in its indirect 
influences. In the home the nurse has opportunities of detecting and 
correcting the causes that produce the trouble for which treatment 
was advised. Often entire families are found to be suffering from the 
same disease for which the child was excluded, showing how utterly 
useless the work in the school would be in such cases without the nurse 
to attack the root of the evil in the home. The nurse on her first visit 
explains why the child has been excluded and what has to be done, 
often giving a practical demonstration of the treatment needed. If 
the condition is one which calls for a physician's services, she urges 
upon the family the necessity of calling their regular doctor or, in the 
case of very poor families, she often takes the child to the proper dis- 
pensary and sees that it gets the treatment required. The nurse's 



The School Nurse 73 

opportunities for advising the family are manifold, as are also her chances 
of noting unsanitary conditions and non-observance of the law and 
reporting the same to the proper authorities. 

In Boston the nurses are under the Department of School Hygiene, 
v^^hich is an integral branch of the educational system. 

The nvirsing division of the department is under the direction of 
one supervising nurse who has at present thirty-four assistants. The 
division is provided for by an additional special appropriation of $25,000 
annually. Rooms are equipped at schools in each district, and each 
nvirse has an assignment of approximately 2,700 pupils. These nurses 
are appointed from a certified list similar to that of other employees 
in the service. The following report of the work of the first twenty nurses 
appointed under this department for the period September 11, 1907, to 
February i, igo8, shows what is possible under this adjunct to health 
and efficiency. 

Diseases of: Ear, 1,492 cases cared for; Eye, 6,078 cases cared 
for, including 3,649 suffering from defective vision; of these 1,131 were 
corrected by oculists ; Nose, 2,602 cases, of which 1,405 had adenoids, 
423 of whom had the obstruction removed; Mouth, 1,765 cases, includ- 
ing 1,686 who had carious teeth; Throat, 1,695 cases, including 683 
of hypertrophied tonsils, and 608 of tonsillitis; Skin, 10,139 cases, all 
of which were followed to their homes and the parent or guardian 
instructed how to care for the same. 

In addition to the above, 2,563 pupils having abrasions and wounds 
received 9,144 dressings; 2,034 miscellaneous affections, including 
350 septic wounds, 312 suffering from renal disease, 121 having rachitis, 
207 suffering from malnutrition, 227 with epilepsy, 126 with chorea, 
and 548 with bronchitis, anaemia, and heart disease, were treated; 
3,293 were taken to family physicians, resulting in 3,202 being cured 
and retvirned to school at the minimum of absenteeism; 4,773 were 
taken to hospitals on request of parents; and 3,223 of these were cured 
and returned to school; 7,559 home visits were made for the purpose 
of instructing or advising parents concerning the children, or in order 
to persuade the parents to seek proper medical or surgical aid for the 
child. There were also 2,882 affections looked after, of which there is 
no classification. These do not include the specific infectious diseases. 

In New York City the following account of the duties of the school 



74 Medical Inspection of Schools 

nurses was given in a pamphlet published by the Department of Health 

in 1906: 

Duties of Supervising Nurse 
The supervising nurse has entire charge of all of the 
nurses. She assigns the niu-ses to duty at certain schools, 
sees that necessary supplies are furnished, instructs the 
nurses in their duties, inspects their work, receives their 
reports of work performed and keeps a record of all 
exaniinations, treatments and diseases treated by each 
nurse in each school. 

Duties of School Nurses 
Each nurse is assigned a group of schools. She reports 
each day at each school, at a certain specified time. 

I . Morning Inspection. 

In a special room, assigned for the purpose, the nurse 
receives all children ordered to report to her for treatment. 
These cases include pediculosis, ringworm, scabies, favus, 
impetigo, molluscum contagiosum and conjunctivitis. 
The treatment used for these conditions is as follows : 

Pediculosis: Children are assembled in groups and 
are instructed orally, and by means of circulars printed 
in a language suited to the nationality of the child, as to 
the methods of home treatment. These cases are not 
treated in school. 

Cases to be Visited by the Nurse at the Home of 
THE Children 

1. Flagrant cases of pediculosis. The mu-se shows 
the mother how to treat the condition and encourages 
persistence. 

2. Excluded cases who do not retvirn at the appointed 
time. 

3. Trachoma cases where treatment is not sought 
regularly. The nurse lu-ges the need of treatment, and 
if necessary takes the child to a dispensary. 



The School Nurse 75 

The nurse is not allowed to treat cases of trachoma. 
Children so affected must report to the nurse each week 
and show a physician's certificate card, properly dated, 
showing evidence that the child is continuously under 
treatment. Persistent failure to show such evidence is 
cause for exclusion. 

2. Routine Inspection. 

When morning inspection has been completed, the 
nurse visits the classrooms and makes a weekly routine 
inspection of the eyelids, hair, skin, and throat of each 
pupil. 

The nurses keep a special set of index cards. All 
cases of contagious disease found are noted on these 
cards. Special cards are kept for recording all cases 
of pediculosis ; these cases are under the exclusive care of 
the nurse. Other cases are noted and ordered to report 
to the medical inspector for the purpose of confirming the 
diagnosis. The nurse must exclude all children showing 
symptoms of diphtheria, scarlet fever, measles, whooping 
cough, chicken-pox, or mumps, and if the inspector is not 
in the school to confirm the diagnosis, telephone the name 
and address of each excluded child to the central office. 
An inspector is then sent to the home of the child and 
takes further charge of the case. 

The nurse forwards each day to the supervising nurse 
a record of the work performed that day, including: 

Number of children examined 

Number of children excluded 

Number of children treated 

Number and character of diseases treated 

Number of visits made to children at their homes 

The nurse also sends to the supervising nurse, each 
week, a report giving the total amount and character of the 
work performed during the week. 



.76 Medical Inspection of Schools 

Dr. Cornell gives the following account of the duties of the school 
nurse in Philadelphia: 

"Five nurses are maintained by the city for work in 
the congested quarters. Their duties consist in curing the 
numerous minor skin diseases existing coincidently with 
poor nutrition and unhygienic surroundings, looking 
after other minor cuts, sprains, etc., occasionally examin- 
ing children for pediculosis, when several cases have 
occurred in a class, and in visiting the parents of children 
suffering from physical defects, for the purpose of iirging 
treatment. Occasional visits are made to dispensaries 
with the children. The efficiency of these nurses depends 
largely upon their personality. As a rule, in foreign 
poverty-stricken sections, they are invaluable. It does 
not appear that their sphere would extend beyond the 
home visiting for the purpose of urging treatment, in the 
other sections of the city. 

" In those schools visited by both the medical inspector 
and the nurse, the nurse is subordinate to the medical in- 
spector. The method of action and record in these schools 
is for the medical inspector to leave the small blue cards, 
each containing the record of some child's physical defect, 
for the nurse's enlightenment. The nurse sends for the 
children by means of these cards, and either treats them 
at the time or makes a note of home visits required. 
When the case is disposed of, she makes such disposition: 
'eye-glasses, Pennsylvania Hospital'; 'sent to Dr. 
Schamberg,' skin specialist; 'glasses. City Hall' — meaning 
a case for free treatment and glasses by the city ophthal- 
mologist, and retiirns these cards to the medical inspector, 
who finally files them at the central office." 



The School Nurse 77 

FORMS USED IN CONNECTION WITH WORK 
OF NURSES 

In the report of the work in Philadelphia quoted above, Dr. Cornell 
mentions the small blue cards made out by the medical inspectors 
which contain the record of some child's physical defect and are left 
for the nurse's enlightenment. The following is a reproduction of the 
card referred to : 



CARD RECOMMENDING PUPIL FOR TREATMENT. 
PHILADELPHIA 

RECOMMENDED FOR TREATMENT 



School Section. 



Name. 



Address 
Cause 



Date of Recommendation. 

(Physician 
Referred to-< Dispensary 
(.Hospital 



Result . 



.Medical Inspector 



Every nurse sends each week a report to the chief medical inspector 
of what she has done during the week. The following is a reproduction 
of the form used: 



78 Medical Inspection of Schools 

WEEKLY REPORT OF NURSE. PHILADELPHIA 

A. A. Cairns, M. D., 

Chief Medical Inspector. 
Dear Sir: — 

The following is a weekly report of Nurse of Schools of 
Fourth Section. 



Week Ending. 














Diseases for which Pupils are Treated. 


















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.23 




































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Old 


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Old 


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Monday .. 


















Tuesday . . 
























































Wednesday 
























































Thursday . 
























































Friday 
























































Saturday . . 




















- 


— 


- 


- 


- 


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Totals 


















Total numb 


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CASES TREATED AT HOMES 


Date. 


Name. 


Address. 


Disease. 










CASES TAKEN TO DISPENSARY 


Date. 


Name. 


Disease. 









Date. 



Nurse. 



The School Nurse 79 

A simpler form of weekly report on the nurse's work is in use in 
Baltimore. 

WEEKLY REPORT OF NURSE. BALTIMORE 

SCHOOL INSPECTION. 

NURSES' WEEKLY REPORT. 
No. of pupils inspected in school 

(Work with School Inspector not included) 

No. of pupils inspected at home 

No. of pupils treated in school 

No. of pupils treated at home 

Schools Visited Nos 

No. of Homes Visited 

DISEASES TREATED IN SCHOOLS: 



DISEASES TREATED IN HOMES: 



REVERSE OF BALTIMORE CARD 

Difficulties, if any, at homes: 

Difficulties, if any, in schools: 

Remarks: 

Date, 

Nurse. 



8o Medical Inspection of Schools 

To sum up the case for the school nurse — she is the teacher of the 
parents, the pupils, the teachers, and the family in applied practical 
hygiene. Her work prevents loss of time on the part of the pupils 
and vastly reduces the number of exclusions for contagious diseases. 
She cures minor ailments in the school and furnishes efficient aid in 
emergencies. She gives practical demonstrations in the home of 
required treatments, often discovering there the soiurce of the trouble, 
which if undiscovered, would render useless the work of the medical 
inspector in the school. The school nurse is the most efl&cient possible 
link between the school and the home. Her work is immensely im- 
portant in its direct results and very far-reaching in its indirect in- 
fluences. Among foreign populations she is a very potent force for 
Americanization . 



CHAPTER VII 

Physical Examinations for the Detection 
of Non-Contagious Defects 

The whole theory on which physical examinations conducted for 
the detection of defects are based rests on a different foundation from 
that underlying medical inspection for contagious diseases. The latter 
is primarily a protective measure and looks mainly to the present 
safeguarding of the community. The former aims at securing physical 
soundness and strength, and looks far into the future. 

It has been brought into being by the great mass of evidence showing 
conclusively that a very large percentage of school children — probably 
from a quarter to a third of all of them — are defective in vision to the 
extent of requiring an oculist's care if they are to do their work properly 
and if permanent injury to their eyes is to be prevented. These con- 
clusions are based upon examinations of hundreds of thousands of 
children in all parts of the world. There is no doubt as to the sub- 
stantial accuracy of the results. More than this, a considerable per 
cent. — probably about five — of school children are so seriously defective 
in hearing that their school work is badly interfered with. Most im- 
portant of all, only a small minority of these dejects of sight and hearing 
are discovered by teachers or are known to them, to the parents, or to the 
children themselves. When children attempt to do their school work 
while suffering from these defects, among the results may be counted 
great injury to the eyes, sometimes resulting in blindness, permanent 
injury to the nervous system owing to eye straining, and depression and 
discouragement owing to inability to hear and see clearly. 

But not only are eyesight and hearing important, there are many 
other defects far from rare among children and having an important 
bearing on their present health and future development which, if dis- 
covered early enough, may easily be remedied or modified. 
6 8i 



82 Medical Inspection of Schools 

The argument for the physical examination of school children is 
based on a recognition of the important bearing of the physical and 
mental condition of the children on the whole process of education. 
It recognizes the necessity of a favorable physical and educational 
environment, and by emphasizing the importance of the effect of sur- 
roundings upon the personality of the individual child seeks to seciu-e 
for each pupil such conditions of life as will secure a full and effective 
development of its bodily strength and mental power. 

In America comprehensive systems embracing thorough medical 
examinations of all pupils are still rare. The oldest such system in 
public schools is of comparatively recent origin. Partial examinations, 
however, have been made in many places and tests of eyesight and hear- 
ing are by no means rare. In the nature of the case there has been so 
great variation in the methods used in conducting these tests that the 
results found in different cities, where examinations have been conducted 
perhaps under radically different conditions, are not directly comparable 
with each other. Nevertheless an examination of the available data 
serves to emphasize the far-reaching importance of doing something 
to better existing conditions and to show that eyesight and hearing 
troubles are not confined to any one locality or to large cities only. 
In the table on page 83 are shown the results of different recently 
conducted eyesight and hearing tests. 

In examining this table one is at once struck by the variations between 
the figures in the column giving the percentages of defective vision 
for the several places. Thus, Bayonne reports only 7.7 per cent, 
defective, while the congested districts of Cleveland report 71.7 per 
cent. Of course, such variations as this at once suggest what is un- 
doubtedly the case, that the results are largely influenced by the methods 
employed by the examiners, and variations from this cause are apt to 
be even more important than those caused by the actual differences 
in existing conditions. Leaving out of account such extreme cases 
as those cited, it will be noticed that in a considerable part of the cases 
the children having defective vision are from 20 to 30 per cent, of the 
whole number examined. 

In the two examinations conducted in Cleveland in 1907, the per- 
centage of those having defective eyesight in the well-to-do district 
was 32.4, while in about the same number of cases in a congested dis- 



Physical Examinations for Non-Contagious Defects 83 

trict it was 71.7. It is said that every endeavor was made to use just 
the same standards in the examinations in these two tests. Certainly 
this is interesting, and suggests the importance of conducting similar 
tests in other cities. 



RESULTS OF VISION AND HEARING TESTS CONDUCTED 
IN PUBLIC SCHOOLS 

p. .„_ Tii-vv Number Defective Per Defective Per 

rLACE. UATE. ExAMINED. VISION. CeNT. HEARING. CeNT. 

Bayonne, N. J 4,610 353 7.7 115 2.5 

Camden, N. J 1906 10,028 2,757 27.7 412 4.1 

Cleveland 1900 30,045 6,221 20.7 

Cleveland, well-to-do dis- 
trict 1907 668 216 32.4 34 5.2 

Cleveland, congested dis- 
trict 1907 616 437 71.7 II 1.8 

Dunfermline 1907 1,526 255 17.0 4.0 

Edinburgh 1904 1,330 574 43.2 162 12.2 

Massachusetts 1907 402,937 99,609 22.3 27,387 6.3 

Counties of Mass. except 

Suffolk 1907 19.9 5.8 

Suffolk County (Boston, 
Chelsea, Revere, Win- 

throp) 1907 30.7 7.7 

Milwaukee 1907 1,960 293 14.9 

Minneapolis 25,696 8,166 30.0 

Minneapolis 1908 710 170 23.9 55 7.7 

New York City 1906 79,065 24,534 31.3 1,633 2.0 

Pawtucket, R. 1 1901 4,663 517 11. i 200 4.3 

Utica, N. Y 1897 6,113 667 10.9 406 6.6 

Worcester, Mass ii,953 2,281 19. i 313 6.6 

Another point which may be of significance is that in the state ex- 
aminations of Massachusetts the percentage of defective vision of the 
coimties of the state outside of Suffolk County was 19.9, while Suffolk 
Coimty, which is almost entirely the city of Boston, reports 30.7 per 
cent. In corroboration of the suggestion that defective vision is more 
prevalent in cities than in country districts are also the figures from 
Scotland, where the city of Edinburgh reports 43.2 per cent, defective, 
while the town of Dunfermline reports only 17.0. 

It is to be noted that a similar situation exists with regard to the 



mCIVIDUAL RECORD CARD, NEW YORK CITY 



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Physical Examinations for Non-Contagious Defects 85 

figures for hearing from these same locahties. The counties of Mass- 
achusetts outside of Suffolk report 5.8 per cent, defective in hearing 
while Suffolk reports 7.7 per cent. Dunfermline reports 4 per cent., 
as contrasted with 12.2 per cent, from Edinburgh. 

In general, from 5 to 6 per cent, of children examined are found to 
have defective hearing. 

Turning our attention now from tests for vision and hearing to more 
comprehensive physical examinations, we are at once attracted to the 
situation in New York. Up to the spring of 1903 the whole attention 
of the medical inspectors in New York had been directed against in- 
fectious and contagious diseases. In March of that year the system 
was so elaborated as to continue with the former work and at the same 
time to include the complete physical examination of each child. 

Since that time there has been but little change in the list of defects 
examined for. Immediately after the morning inspection for conta- 
gious diseases has been concluded the inspector receives the children 
of a class in turn in a special room set aside for the purpose and examines 
them for sight, hearing and physical defects. The headings under 
which entries are made can be seen by referring to the reproduction of 
the individual record card in use in the New York schools. 

In every case where a defective condition is found to exist the parent 
of the child is notified by means of a printed postal card form. The 
postal cards used are of the "reply" form. The postal card informing 
the parent that his child has some physical defect has on it the direc- 
tions: " Take the child to your family physician for treatment and advice. 
Take this card with you to your family physician." Attached to this 
card is another which the family physician to whom the case is referred 
is asked to fill in, telling what action he has taken, and mail to the chief 
medical inspector. This system allows of following up the cases. 
If the reply card is received, the authorities know that action has been 
taken in regard to the case. If no reply is received, the case demands 
further attention. 

The results of the New York examinations have attracted wide- 
spread attention, and a large number of newspaper and magazine articles 
have been written about this work in New York. There has been 
much discussion as to whether the conditions found by the doctors in 
New York were typical of conditions existing in other cities or were 



86 Medical Inspection of Schools 

POSTAL CARD NOTICE TO PARENTS, NEW YORK 

** This Notice Does NOT Exclude This Child From School " 

DEPARTMENT OF HEALTH 
THE CITY OF NEW YORK 

190 

The parent or guardian of 

of attending P. S 

is hereby informed that a physical examination of this child seems to 
show an abnormal condition of the 



Remarks , 



Take this child to your family physician for treatment and advice. 
Take this card with you to the family physician. 

THOMAS DARLINGTON, M. D., 

Commissioner of Health. 
HERMANN M. BIGGS, M. D., 

General Medical Of&cer. 



REVERSE OF CARD 
TAKE THIS CARD TO YOUR PHYSICIAN 

The Physician in charge is requested to fill out and forward this 
postal after he has examined this child. 

I have this day examined 

of P. S and find the following condition: 



and advised as follows: 

Respectfully yours, 

Date 



Physical Examinations for Non-Contagious Defects 87 

exceptional. Unfortunately not enough work of a similar nature has 
been done in other places to furnish data for answering these questions, 
and where the work has been done the results are not usually in such 
statistical form as to allow of comparison. Almost the only available 
figures are from Minneapolis and are for a small number of cases. 
Nevertheless it is interesting to compare these figures with those for 
New York for the year 1906. 



PHYSICAL EXAMINATIONS IN NEW YORK AND 
MINNEAPOLIS 

New York City, Minneapolis, 

1906. Per Cent. 1908. Per Cent. 

Number examined 78,401 100. o 710 loo.o 

Bad nutrition 4,921 6.3 166 23.3 

Anterior cervical glands 29,177 37.2 377 53.0 

Posterior cervical glands 8,664 n-o 

Chorea 1,380 1.7 2 0.2 

Cardiac disease 1,096 1,4 15 2.1 

Pulmonary disease 757 .9 30 4.2 

Skin disease 1,558 1.9 12 1.6 

Deformity of spine 424 .5 ... ... 

Deformity of chest 261 .3 ... 

Deformity of extremities 550 .7 ... ... 

Defective vision 17,928 22.8 170 23.9 

Defective hearing 869 i.i 55 7.7 

Defective nasal breathing 11,314 i4-4 •-- 

Defective teeth 39>597 55-° 309 43-5 

Defective palate 831 i.o 2 0.2 

Hypertrophied tonsils 18,306 23.3 221 31. i 

Postnasal growth 9,438 12.0 91 12.8 

Defective mentality 1,857 2.3 ... 

Where treatment was necessary... 56,259 71.7 462 65.1 



On the whole the figures in the per cent, columns show substantial 
agreement. It is to be supposed that the great difference under the 
heading " Bad nutrition" (6.3 per cent, in New York and 23.3 in Minne- 
apolis) is due to a different standard rather than to any great difference 
in conditions. Under "Defective hearing," again, there is a striking 
difference, the New York figure being i.i, while that of Minneapolis 
is 7.7. As so low a percentage as that given for New York is very 



88 Medical Inspection of Schools 

rarely found elsewhere, here again it must be concluded that the 
standard in New York must be less rigid than in other places. 

Perhaps the most interesting figures of all are those for "Where 
treatment was necessary." The percentages are 71.7 for New York 
and 65.1 for Minneapolis. 

This is a feature of interpreting the results of the work of physical 
examinations which has caused many misapprehensions. It has been 
stated again and again that the results of physical examinations in 
New York proved that two-thirds of all the school children were defec- 
tive, and such statements have aroused much discussion and called forth 
some denials. The trouble is one of words rather than facts. To 
use the word "defective" as it has been used in this way is to give it a 
new meaning. What the figures really show is that more than two- 
thirds of the children are found to have defects serious enough to record 
them and which call for attention from a physician, surgeon or dentist. 
Nevertheless the defects so recorded may be nothing more serious than 
a carious tooth. 

Judgment as to what constitutes a defect serious enough to warrant 
including the child in the class "defective" varies greatly in different 
places. Recently newspaper articles announced that examinations of 
school children in Sioux City showed that 80 per cent, were defective, 
while a little later they announced that only 18 per cent, were defective 
in Minneapolis. This latter figure represented the proportion the physi- 
cians in the latter city considered "seriously defective." Of course, 
it must be remembered in this connection that the perfect human 
animal is exceedingly rare. At a recent examination in Chicopee, 
Mass., out of 500 pupils examined only|one was reported as having 
perfect teeth, and this one was found to have spinal trouble, so that not a 
single pupil was reported as being perfectly sound physically. 

All this does not mean, however, that our schools are filled with 
physical wrecks. While the results of the examinations prove beyond 
doubt the need for finding out the facts and taking steps to have defects 
remedied, the need for moderation of statement in making public the 
results is no less apparent. 

In any system of medical inspection which includes the feature 
of physical examinations the matter of keeping records is of the greatest 
importance. To begin with, a good system of individual records is 



Physical Examinations for Non-Contagious Defects 89 

imperative. This is a field of work where general information will 
not do. There must be a complete individual record for each child. 
This record card or blank must have on it spaces for recording the 
results of subsequent examinations as well as the initial one. If the 
results of the work are to be of real practical value, there must be the 
closest connection between the records of the physical examinations 
and the classroom work. It does no good to have a record on a card 
in the principal's room or in the ofiice of the board of health to the 
effect that Willie is stone deaf in the right ear, if the teacher knows 
nothing of the fact and still has Willie seated in the back left-hand 
corner of the room. It is also obvious that if the records do not follow 
the child from room to room, and school to school, in case of transfers, 
much of the work is soon rendered useless. 

These are some of the reasons why a system of medical inspection 
with physical examinations is an entirely different problem, from the 
point of view of the school administration, from a system for the detec- 
tion of contagious diseases only. 

Experience proves that the latter sort of work can be handled satis- 
factorily by boards of health. In the system having physical examina- 
tions as an important feature the educational authorities must in any 
event have an active participation in the work, and will probably succeed 
much better if they have it entirely in their own hands. 

The necessity for applying the information gained through the work 
of the school physician to the work of the classroom has been recog- 
nized in Los Angeles and some other cities by having the teacher's roll 
books so made that in case any child has a physical defect, the fact is 
entered in a space beside his name in the book. 

Pasadena, California, recognizes the importance that the teacher's 
intimate knowledge of the child and his habits has for the school physi- 
cian who is conducting physical examinations. In that city individual 
cards are used for recording the results of the physical examinations 
made by the school doctors, and on the reverse of the cards are blanks 
which the teacher fills in, indicating the points which her knowledge 
of the child leads her to believe require attention. Of course, the teacher 
fills in her side of the card first, and the physician uses the information 
as a guide and assistance in making the physical examinations. 



90 Medical Inspection of Schools 

RECORD CARD, SHOWING TEACHER'S COMMENTS ON 

HABITS AND PECULIARITIES OF PUPIL. 

PASADENA, CAL. 

HEALTH DEPARTMENT, PASADENA PUBLIC SCHOOLS 

Date 

Pupil's Name 



Parent's Name 


Address 


I 


Posture 


2 


Nutrition 


3 


Color 


4 


Activity, mental 


5 


Activity, physical 


6 


Teeth: crooked, prominent, decayed 


7 


Mouth breather 


8 


Frequent absences 


9 


Bad behavior 


lO 


Inattention 


II 


Delinquency in studies 


12 


Squinting, or other eye symptoms 


13 


Deafness 


14 


Nasal voice 


15 


Frequent colds 


16 


Skin diseases or pimples 


17 


Twitching of eyes, face or any part 


18 


Offensive breath 


19 


Over development, physical 


20 


Under development, physical 


21 


Uncleanliness 


22 


Vicious personal habits 


23 


Signs of fever 


24 


Signs of any contagious disease 


25 


Cough 



The Teacher will please fill in the blanks at the top of this card, and check off the points 
which she thinks require attention. 



Physical Examinations for Non-Contagious Defects 91 

REVERSE OF CARD, SHOWING BLANKS FILLED IN BY 
SCHOOL PHYSICL^ 



PHYSICAL EXAMINATION 



No. 



Heart 



Lungs 



Eyes 



Ears 



Nose 



Throat 



Teeth 



Contagious Disease 



Skin Disease 



Special Data 



Recommendations 



Results 



Medical Examiner. 



92 



Medical Inspection of Schools 



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Physical Examinations for Non-Contagious Defects 93 



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94 



Medical Inspection of Schools 



A similar, but more highly developed, system is in use in the schools 
of Los Angeles, California. There a standard five by eight inch index 
card is used for the record of each pupil. One side is filled out by the 
teacher and the other by the school physician. Professor George L. 
Leslie, Director of the Department of Health and Development of 
Los Angeles City Schools, writes as follows concerning the use of this 
card: 

" We yoke the school teacher and the physician together 
as nearly as possible by the use of the record card. The 
plan is not too difficult for the teachers of the schools, 
and very materially aids the physicians in their work. 
It also emphasizes the fact that both teachers and parents 
ought to and must know more of the common develop- 
mental conditions of boys and girls as a matter of every 
day living, if physical excellence and not degeneracy is to 
show in the growth and. development of the young." 

A simple card for keeping the individual record of physical examina- 
tions is in use in Utica, N. Y. It has the shortcoming of not having 
spaces provided for recording more than one examination. 



PHYSICAL RECORD CARD, UTICA, N. Y. 

CITY OF UTICA— DEPARTMENT OF PUBLIC SAFETY 

BUREAU OF HEALTH 
DIVISION OF SCHOOL INSPECTION 



School 

Name 

1 Nutr. 

2 Enl. Cerv. Gl. 

3 Chorea 

4 Card. Dis. 

5 Pulm. Dis. 

6 Skin Dis. 

Remarks 



PHYSICAL RECORD 

Class 



.Date- 



-Age- 



G. B. 

'Y.N. 
A. P. 

' Y. N. 
Y.N. 
Y.N. 
Y.N. 



r Spine Y. N. 

7 Defective ] Chest Y. N. 

{ Extrem.Y.N. 

SDef.Vis. {^^^Jy^N: 

9 Def. Hear. Y. N. 

lo Def. Nas. Breath. Y. N. 



-A ddress 

11 Teeth G. B. 

12 Deform. Palat. Y. N. 

13 Hyper. Tons. Y. N. 

14 P. Nas. Growths Y. N. 

15 Mentality G. B. 

16 Treatment 
necessary Y. N. 

17 Nationality 



Medical Inspector. 



Physical Examinations for Non-Contagious Defects 95 

On this card the letter G stands for "good," B for "bad," Y for 
"yes," N for "no," A for "anterior," P for "posterior." In filling 
the card out the letters are crossed out as required. 

The physical record card now in use in the New York schools 
(see page 84) has spaces provided for records of annual examinations 
for nine years. A card having spaces for five examinations is in use 
in Asbury Park, N. J. 



PHYSICAL RECORD CARD, ASBURY PARK, N. J. 
ASBURY PARK PUBLIC SCHOOLS 

DEPARTMENT OF MEDICAL INSPECTION 



No. Date 




Class 


Name 




Age 








19 


19 


19 


19 


19 














Weight 












Height 












Inspiration 












Expiration 












p 

rvrr- 












Naso-Pharynx 












L. 












Nasal Septum 












Oen'l 
Condition 












Teeth 














19 


19 


19 


19 


19 


Heart 












Lungs 












Throat 












Color Sense 












I R. 












/l. 












Remarks 


. Date of Last Successful Vaccination 





Two simple forms for notifying the parent of the presence of some 
physical defect in the child that requires attention are in use in Somer- 
ville, Mass., and Ann Arbor, Mich. Neither one has any "follow-up" 
provision such as that described in connection with the New York 
notification card. 

The Ann Arbor form is made like a bank check with a stub and is 
perforated for separation. These forms are bound in a book. This 
plan has the advantage of providing, with but little additional work, a 
record of the notifications sent. 



96 Medical Inspection of Schools 

NOTIFICATION TO PARENTS, SOMERVILLE, MASS. 

(No. 9) 

THIS NOTICE DOES NOT EXCLUDE THE PUPIL FROM SCHOOL 

^omerbiUe poarb of Healtii 

Medical Inspection Department 

Somerville, 190 

The parent or guardian of 

at is hereby informed that a physical 

examination by the medical inspector seems to show the following 
abnormal condition: — 

You are advised to take this child to your family physician for 
advice and treatment. Very respectfully, 

BOARD OF HEALTH. 



NOTIFICATION TO PARENTS, ANN ARBOR, MICH. 
Ward Room • Ann Arbor Public Schools 



Pupil's Name 



Sent by . 
Address . 
Note . . 



Date. 



Date 

Mr 

Dear 

It has come to our notice that your, 
needs medical attention relative to 



and we would suggest that you place 

Under the Care of a Physician as Early 

AS Possible, so that will he 

in a better condition, physically, to continue 

studies. 

Respectfully, 



ELLIOTT KENT HERDMAN, M. D., 



Board of Education. 



Medical Inspector, 



Physical Examinations for Non-Contagious Defects 97 

There is one branch of medical inspection v/hich has been given 
decided attention abroad, but until very lately has received very scant 
notice in this country. This is the care of the teeth of children. In 
Germany not less than thirty cities support free dental clinics where 
work is done on the teeth of school children. The records show that 
this has resulted in a great improvement in the health of the children 
and a decided diminution of absences. Wherever children's teeth are 
examined, a great majority are found to be suffering from more or less 
serious defects. In Germany, where account is taken of even the 
smallest imperfection, the per cent, of the defectives is reported to be 
as high as 96. In the examinations conducted in Dunfermline, Scot- 
land, in 1907, the same result was found. Ninety-six per cent, of the 
children are reported as having defective teeth, and it is stated that 
among 2200 pupils of the schools not a single child was foimd who had 
had dental care or who had teeth filled or otherwise attended to. 

There is some indication that the importance of sound teeth even 
in small children is commencing to be realized by medical inspectors 
in America. In the town of Northampton, Massachusetts, one of the 
blanks used by the medical inspectors is a small chart showing in out- 
line a full upper and lower set of teeth. By making marks on these 
pictured teeth the medical inspector in making his examination indicates 
which of the teeth of the child are in need of attention. 



TEETH CHART, NORTHAMPTON, MASS. 

Name Address 




New Bedford and Waltham are two other Massachusetts cities 
where attention is given to this subject. In New Bedford the children 
are supplied with leaflets containing a catechism on the care and iise 
7 



98 Medical Inspection of Schools 

of the teeth. The leaflet is endorsed by the Medical Academy of 
Dental Science, the Dental School of Tufts College, and the Dental 
School of Harvard University. 



LEAFLET ON THE CARE OF THE TEETH SUPPLIED TO THE 
CHILDREN, NEW BEDFORD, MASS. 

What are the teeth for? 

Not merely for ornament. Their chief use 
is to prepare the food for the stomach — to 
grind the food and mix it with saliva. Food 
which is not thoroughly chewed causes in- 
digestion and constipation. 

How long should the teeth last? 

To the end of life. 

How do we lose them? 

By decay and loosening. 

What causes teeth to decay? 

Bits of food and candy sticking to the teeth ; 
also a poor physical condition. 

Where does the food lodge? 

All along the edge of the gums, between the 
teeth, and in the crevices of the grinding 
surfaces. 

Can decay be prevented? 

Yes, to a large extent. 

How can decay be prevented? 

By scrubbing the teeth thoroughly with a 
tooth-brush, tooth-powder and water; and 
by keeping up the general health. 

How often should the teeth be cleaned? 

At least twice a day — after breakfast and at 
bed time. Better after each meal. 



Physical Examinations for Non-Contagious Defects 99 

Should the gums be brushed? 

Yes. Moderate friction helps to keep them 
heakhy. 

How often should tooth-powder be used? 

At least once a day — at bed time. 



Twice a year at least a Dentist should 
carefully examine the teeth. 

A bad condition of the throat, the nose 
and the ears is made worse by decayed 
teeth. They add to the chances of catch- 
ing infectious diseases. Well cared-for 
teeth and a clean mouth help prevent 
TUBERCULOSIS. 

Cleanliness is the best guard against 
disease. 



Waltham distributes a leaflet on the care of the teeth to the parents 
of the school children. 



LEAFLET ON THE TEETH AND THEIR CARE, 
WALTHAM, MASS. 

To Parents : — 

You are reminded of the necessity for early care of 
children's teeth. With such care, the teeth may be pre- 
served throughout life. This will not only save much 
inconvenience and discomfort in later life, but it may 
enable the child in the meantime to live a more vigorous 
and hence a more successful life. 

The condition of the teeth has much to do with the 
general health. 

The following cautions, abbreviated from those 



100 Medical Inspection of Schools 

issued to teachers and school physicians by the Massa- 
chusetts board of education, are commended to your 
attention: 

Unclean mouths promote the growth of disease 
germs, and cavities in the teeth are centers of infection. 

Irregularities of the teeth, especially those which make 
it impossible to close the teeth properly, thus leading to 
faulty digestion and faulty breathing, should receive care- 
ful treatment. 

The first permanent molars are perhaps the most im- 
portant teeth in the mouth. They come at about the 
sixth year immediately following the temporary teeth, and 
are the most frequently neglected because they are often 
mistaken for temporary teeth. 

It should be known that decay of the teeth is caused 
primarily by the fermentation of starchy foods and sugars, 
and that the greatest factor in preventing disease of the 
teeth is the removal of food particles by frequent brushing. 
Children should be prevented from eating crackers and 
candy between meals, and when possible the teeth should 
be cleaned after eating. Inspection of the teeth by a 
dentist should be made at least once or twice a year. 

Your attention is also called to the prevalence of 
maladies of the nose and throat. 

The health of a child and his ability to do his school 
work may be seriously impaired by the presence of adenoid 
growths. When a child shows obstruction of the nose by 
mouth breathing, snoring, continual discharge, or recurrent 
ear trouble, adenoids should be suspected. 

Enlarged tonsils, recurrent tonsillitis, and enlarge- 
ment of the glands in the neck also constitute a serious 
handicap to the child. Either condition must be remedied 
before he can have a fair chance in the world, and the 
earlier the better. The family physician should be con- 
sulted and the child given such treatment as he may advise. 

Waltham, Mass., 

Jan. I, 1908. 



Physical Examinations for Non-Contagious Defects loi 

It is, of course, of the utmost importance that the physical defects 
disclosed by the examination of the school physician be given attention 
by the parents of the child, and through them brought before a physician 
and remedied if possible. It is of very slight practical utiUty to discover 
that a child has enlarged tonsils or defective vision if the discovery 
results merely in the addition of one to the statistical table of the defects 
discovered. Unless the cases are followed up, and unless parents can 
be persuaded or coerced into having their children given the necessary 
medical attention, it is obvious that a large proportion of the work of 
the school physician in making the examinations will be of scant utility. 
Nevertheless, despite the obvious importance of ascertaining whether 
physical examinations result in any good, attempts made to discover 
and report the number of cases where glasses have been supplied or 
medical attention given are few in number and ineffective in method. 

A careful examination of the reports of the superintendents of schools 
of the ICO largest cities of their country, of the reports of the superin- 
tendents of schools of such other cities as are known to have systems 
of medical inspection, and of a large number of magazine and newspaper 
articles by recognized authorities, fails to bring to light a single official 
report giving the three essential factors, that is, total number of children 
examined, total number having physical defects, and total number of 
cases where the parents have taken steps to have remedied the defects 
discovered. Such information as is discovered is scant and indefinite. 
The search referred to above has brought to light solely the following 
information : The Superintendent of Schools of Newton, Mass., reports : 
"In every case in which the defect was considerable the parents of the 
child were notified and advised to consult a competent oculist or the 
family physician. Very many, if not all, responded, to the great benefit 
of their children." 

The Superintendent of Schools of Somerville says, "At least 600 
cases have been professionally treated and parents, as a rule, have 
gladly cooperated with the teachers." He does not state from how 
many defective children the 600 cases treated came. It seems proba- 
ble, however, that among the 3753 cases of children reported examined 
in 1906, 600 received professional treatment. If this interpretation be 
correct, it means that 15.9 per cent, received the needed medical treatment. 

The City Superintendent of Schools of New York City says in his 



102 Medical Inspection of Schools 

report for 1907: "Examinations for physical defects were made only 
in 248 schools, less than one-half the total number. In three-fourths 
of the cases in which defects were found the examinations conducted 
by the Department of Health serve only for the purpose of piling up 
useless statistics." If these statements are correct, the physical examina- 
tions as conducted in New York result in about one-sixth of the children 
being examined and about 25 per cent, of those examined receiv- 
ing attention. 

The most definite information is given in the report of the Superin- 
tendent of Schools of Cleveland for 1907. In this city the Department 
of Physical Training conducted an examination of 30,000 children in 
grades three to seven with respect to the condition of eyes, ears, nose 
and teeth. About 50 per cent., or 15,000, were found to be suffering 
from physical defects more or less serious. Strenuous endeavors were 
made to secure measures looking for the removal or alleviation of the 
defects discovered. By the cooperation of principals, teachers, dis- 
pensaries, physicians and parents corrections of the defects were secured 
in 3,388 cases, or 22.5 per cent. 

In writing of the medical inspection of schools in Philadelphia Dr. 
Walter S. Cornell, Assistant Medical Inspector, says: 

"The obtaining of eye glasses by the children, after 
official recommendation, follows in about one-fourth or 
one-fifth of all cases in the better resident sections, where 
one would suppose professional advice would be thankfully 
followed. Among the poorer classes the proportion is 
about one-third — imder vigorous urging, one-half. Among 
the foreign population, who receive official recommenda- 
tions with great respect, owing to their ignorance of 
English, the proportion of children who obtain glasses, 
when this is supervised by the nurse, is in my own district 
at least nine-tenths. The treatment of enlarged tonsils and 
adenoids follows recommendations in about one-third of 
the cases. The better classes are more alive to the evil 
consequences following these conditions, and respond fairly 
with their cooperation. The middle and poorer classes 
appear extremely indifferent. The foreigners usually 



Physical Examinations for Non-Contagious Defects 103 

go to the nearest dispensary, but their dread of an opera- 
tion deters many of them from allowing anything but 
simple local treatments, which are worthless. The other 
affections are remedied in probably one-third of the cases. 
The contagious cases, of course, are remedied, since action 
is necessary before the child will be re-admitted to school." 

This reference to the proportionately better results obtained in 
poorer sections and among foreign people is certainly interesting and 
far from flattering to American pride. Testimony of somewhat similar 
nature is given in the report of School Nurses of Harris burg, Pa.: 

"The white children of American parents are propor- 
tionately less cleanly in person and dress than any other 
class. The foreigners, especially the Hungarians, are the 
most cleanly. The negroes are almost without exception 
tidier than the white, and in exposed parts cleaner." 

To sum up the matter of physical examinations of school children 
for the detection of physical defects, we are confronted by the great 
mass of evidence showing with convincing force that a large percentage 
of all school children are suffering from physical infirmities which 
prevent them from making adequate use of school facilities. The pity 
of it is, too, that practically all such conditions could be prevented or 
cured if detected early in life. In the physical examinations by trained 
physicians a means is offered for detecting these conditions, and with 
the campaigns of education now being vigorously pushed in so many 
parts of the country by so many earnest leaders, social machinery for 
remedying the defects discovered must soon be established. 



CHAPTER VIII 

Vision and Hearing Tests by Teachers 

There is considerable divergence of opinion among authorities on 
medical inspection as to whether or not the room teacher is competent 
to detect signs of contagious diseases among her pupils. There is 
much less doubt expressed as to the ability of the room teacher, especially 
if she be given a little careful training, to successfully examine her 
pupils to detect the presence of eye troubles, defective hearing, and 
even the presence of the more easily detected nose and mouth defects. 

Under the provisions of the Massachusetts statute (printed in full 
in Chapter XI on "The Legal Aspects of Medical Inspection") each 
teacher is required to examine her pupils at least once a year for the 
purpose of testing their sight and hearing, and to make a report on the 
results found. During the school year 1907-8, the New York State 
Department of Health is conducting a similar examination in the 
graded schools in incorporated villages of the State. 

Somewhat similar work is being done by the State Board of Health 
of Utah. 

In Connecticut the law provides that teachers shall test the eyesight 
of their pupils according to the instructions furnished by the State 
Board of Education. These tests are made triennially. The law 
provides that teachers shall notify in writing the parents or guardians 
of pupils found to have any defect of vision or disease of the eyes, and 
also that the results of the tests shall be reported to the State Board of 
Education. 

As these four examinations are so extensive, are conducted under 
State authority, and are the result of careful thought and preparation 
on the part of well-qualified physicians of large experience, it seems 
worth while to give here a somewhat extended account of the Massa- 
chusetts system and to show also, although more briefly, what is being 
done under the State Boards of New York, Connecticut, and Utah. 

104 



Vision and Hearing Tests by Teachers 105 

The policy of the legislators of the State of Massachusetts in inserting 
into their statute mandatory provisions that the tests for sight and hearing 
should be conducted by the teachers themselves, rather than by special- 
ists, has evoked many expressions of surprise and some of criticism. 
These provisions were inserted on the recommendation of the special- 
ists themselves, who deemed that such tests were wholly within the 
capacity of the teacher. It was the opinion that the children would be \< 
subjected to a less nervous strain than if tested by a stranger and would, 
therefore, exhibit themselves in a more natural way. It is the intention 
of the Massachusetts law that a scientific examination by specialists 
shall be made in cases where defects are apparently revealed by the 
teacher's tests. 

For this piurpose there are furnished blanks on which the teachers 
notify the parents of apparent defects and advise consulting a specialist. 
During the first year that the law was in operation, the returns show 
that such notifications have been sent in 84,012 cases. 

During the hearings before the State Committee on Ways and Means 
when the Massachusetts medical inspection bill was being considered, 
a mass of evidence was presented by experts bearing upon the question 
as to whether or not such examinations could be successfully conducted 
by teachers. The high standing of the three gentlemen who subscribed 
to it makes the following opinion particularly significant: 

It is the opinion of the undersigned, based upon pro- 
fessional experience, that school teachers, with the aid of 
printed directions properly prepared, are, because of 
their acquaintance with the individual children under 
their charge and their subsequent ability to communicate 
with them and to find out what is in their minds, more capa- 
ble of making a satisfactory examination of the hearing of ^ 
such children than a doctor other than a specialist called 
in for the purpose would be likely to be. 

(Signed) Clarence John Blake, M.D. 

D. Harold Walker, M.D. 

William F. Knowles, M.D. 

The same opinion with regard to eyesight was emphatically ex- 
pressed by Dr. Myles Standish, who represented the Massachusetts 



io6 Medical Inspection of Schools 

Medical Society at the hearing, as it was also by Dr. Charles H. Williams 
and Dr. O. F. Wadsworth. It is the nearly universal testimony of 
experts. In "The Sight and Hearing of School Children," Dr. David 
W. Wells says in regard to such tests, "The lack of normal vision is 
quickly determined, and probably not more than 15 per cent, of those 
needing treatment would be overlooked." 

In "The Necessity for the Annual Systematic Examination of 
School Children's Eyes, Ears, Nose, and Throats by School Teachers," 
Dr. Frank Allport says, "Concerning the incompetency of teachers, 
I have only to say that any one who is competent to be a teacher can 
make the tests with perfect ease. From three to five minutes a pupil 
is aU the time that is required." A similar opinion is strongly ex- 
pressed by Professor Leslie, who has conducted extensive and successful 
work in the Los Angeles public schools. In the Report of the Superin- 
tendent of Schools for 1906-7 he gives the following account of this 
work by the teachers : 

" In this work the schools have made a good beginning. 

Throughout the grades special instruction has been given 

to principals and teachers in eye and ear testing, detection 

of adenoid growths and enlarged tonsils; and corrective 

training for defective chest conditions and spinal curvature 

has been emphasized. Teachers have been urged to study 

with care the nutrition, vitality, and endurance exhibited 

by individual pupils, especially those who were failing or 

getting on poorly. 

(^ " In the graded schools the only apparatus used has been 

S Snellen's Test Types, Fray's Astigmatic Charts, and the 

^ multiple Maddox rod. 

"The eyesight has been tested and the visual fraction 
for each eye recorded. The hearing has been tested by 
either watch or voice test and the pupils seated accordingly. 

" In a part of the schools muscular imbalance has been 
tested in case of those pupils showing little endurance, who 
were easily fatigued, or otherwise seemed in poor working 
condition. 

"Reports of these tests for all the schools are recorded 



V 



Vision and Hearing Tests by Teachers 107 

in the teachers' registers. Examination of these reports 
justifies the statement that much excellent work has been 
done. The results in many of the schools tally well with 
results obtained in certain eastern cities, where such work 
has been done by persons who have had some special 
training along these Hnes. 

"The results show that a fair degree of accuracy can be 
attained by the average teacher if she will give careful 
attention to the simple tests used. 

" The difficulties experienced by many teachers largely 
disappear when simple demonstrations of the work are 
given. 

" For this purpose, as far as time would permit, I have 
asked the teachers of different buildings to keep defective 
children at the close of school. The teachers remaining 
and working with me, we have tested these children. 
After such testing, teachers have completed their work in 
this line with much more certainty and assurance and 
with increased interest and good results. 

"Time has not been at hand to carry out work in this 
particular as it ought to be done. That which is most needed 
is personal help to the teachers, in the study of pupils." 

SIGHT AND HEARING TESTS IN MASSACHUSETTS 

Vision and hearing tests are made in accordance with the following 
directions prescribed by the State Board of Health. The materials 
for the tests are distributed to all teachers by the State authorities. 

COMMONWEALTH OF MASSACHUSETTS 

Chapter 502, Acts of 1906 

Directions for Testing Sight and Hearing (Prepared by 

the State Board of Health). 

To Test the Eyesight 

Hang the Snellen test letters in a good, clear light 
(side light preferred), on a level with the head. Place 



io8 Medical Inspection of Schools 

the child 20 feet from the letters, one eye being covered 
with a card held firmly against the nose, without pressing 
on the covered eye, and have him read aloud, from left to 
right, the smallest letters he can see on the card. Make a 
record of the result. Children who have not learned 
their letters, obviously, cannot be given this eyesight test 
until after they have learned them. 

(Note. — When not in use, the chart of test letters 
should be placed in the envelope in which it is sent, to 
keep it from becoming soiled and illegible. When 
damaged, a requisition should be made on the State Board 
of Education for a new chart.) 

To Record the Acuteness of Eyesight 

There is a number over each line of test letters, which 
shows the distance in feet at which these letters should be 
read by a normal eye. From top to bottom, the lines on 
the card are numbered respectively 50, 40, 30, and 20. 
At a distance of 20 feet the average normal eye should 
read the letters on the 20-foot line, and if this is done 
correctly, or with a mistake of one or two letters, the vision 
may be noted as f ■§■, or normal. In this fraction the 
numerator is the distance in feet at which the letters are 
read, and the denominator is the number over the smallest 
line of letters read. If the smallest letters which can be 
read are on the 30-foot line, the vision will be noted as 
"1^; if the letters on the 40-foot line are the smallest 
that can be read, the record will be |^; if the letters 
on the 50-foot line are the smallest that can be read, the 
record will be -f^. 

If the child cannot see the largest letters, the 50-foot 
line, have him approach slowly until a distance is found 
where they can be seen. If 5 feet is the greatest distance 
at which they can be read, the record will be /q- (yV 
of normal) . 

Test the second eye, the first being covered with the 
card, and note the result, as before. With the second 



Vision and Hearing Tests by Teachers 109 

eye have the child read the letters from right to left, to avoid 
memorizing. To prevent reading from memory, a hole i^ 
inches square may be cut in a piece of cardboard, which 
may be held against the test letters, so as to show only one 
letter at a time, and may be moved about so as to show 
the letters in irregular order. A mistake of two letters 
on the 20 or the 30-foot lines, and of one letter on the 40 
or 50-foot lines, may be allowed. 

Whenever it is foimd that the child has less than normal 
sight, f^, in either eye, that the eyes or eyelids are 
habitually red and inflamed, or that there is a complaint 
of pain in the eyes or head after reading, the teacher will 
send a notice to the parent or guardian of the child, as 
required by law, that the child's eyes need medical atten- 
tion. 

Method of Testing Hearing 

If it is possible, one person should make the examina- 
tions for an entire school, in order to insure an even 
method. The person selected should be one possessed of 
normal hearing, and preferably one who is acquainted with 
all the children, the announcement of an examination 
often tending to inspire fear. 

The examinations should be conducted in a room not 
less than 25 or 30 feet long, and situated in as quiet a place 
as possible. The floor should be marked off with parallel 
lines one foot apart. The child should sit in a revolving 
chair on the first space. 

The examination should be made with the whispered or 
spoken voice; the child should repeat what he hears, and 
the distance at which words can be heard distinctly should 
be noted. 

The examiner should attempt to form standards by 
testing persons of normal hearing at normal distances. 
In a still room the standard whisper can be heard easily 
at 25 feet, the whisper of a low voice can be heard from 
35 to 45 feet, and of a loud voice from 45 to 60 feet. 

The two ears should be tested separately. 



no Medical Inspection of Schools 

The test words should consist of numbers, i to loo, 
and short sentences. It is best that but one pupil at a time 
be allowed in the room, to avoid imitation. 

For the purpose of acquiring more definite information 
concerning the acuteness of hearing, one may have recourse 
to the 512 V. s, (vibrations per second) tuning fork and 
the Politzer acoumeter. 

For very yoimg children a fair idea of the hearing may 
be obtained by picking out the backward or inattentive 
pupils, and those that seem to watch the teachers' lips, 
placing them with their backs to the examiner, and asking 
them to perform some unusual movement of the hand, 
or other act. 

The test card used is the familiar Snellen chart. A reproduction of 
the form used by the Massachusetts authorities is shown on page in. 

The results of the examinations are recorded by the room teacher 
on double sheets, having spaces for recording the results of the examina- 
tion of fifty pupils. A reproduction of the sheet heading is given on 
page 112. 

A report of the results for each school is forwarded to the superin- 
tendent by the teacher or principal. 



REPORT OF SIGHT AND HEARING TESTS TO SUPERINTEN- 
DENT OF SCHOOLS, MASSACHUSETTS 

CommontDealtfi of jWasissacfjusietts; 

Chap. 502. Acts of 1906 
Report of Sight and Hearing Tests to Superintendent of Schools 

Town ] 

or \ School 

City J 

190 

Number of Pupils enrolled in the school 

" found defective in eyesight 

" found defective in hearing 

" of parents or guardians notified 

Teacher or Piiacipal. 



Vision and Hearing Tests by Teachers iii 

SNELLEN CHART FOR TESTING EYESIGHT 

(Printed on heavy white cardboard, size ii x 14 inches.) 
COMMONWEALTH OF MASSACHUSETTS. 

CHAPTER 502, ACTS OF I906. 

SNELLEN'S TEST LETTERS FOR MEASURING THE ACUTENESS 

OF VISION. 




50 Feet 




L D 



40 Feet 



L O E D 




30 Feet 



O T P E C L 



20 Feet 

P T O L D E C 



RECORD OF SIGHT AND HEARING TESTS, 

MASSACHUSETTS 



>C^ 







O 

o 

o 
en 



O 



a 

o 

H 



U 



to 










w 


lU 
(U 

.9 

o 

a 
B 

•3 
ii 

ID 

a 






CIS 

m 

bo 

5 




O 

2 

H 
W 








>> 

5 






f4 


d 

e 

ei 

a 
u 
rS 
m 

a 

1 
3 

a 

c« 
A 
O 

1 

0) 

u 

o 

a 

a 







Vision and Hearing Tests by Teachers 113 

In addition to these reports, the teacher is required to notify the 
parent or guardian of each child found to have some trouble with the 
ears or eyes. Notification cards for this purpose are furnished by the 
State Board. 



NOTICE TO PARENT OR GUARDIAN 

Commontpealtj) of JHasisiacijusiettsJ 

NOTICE TO PARENT OR GUARDIAN 

In accordance with Chapter 502 of the Acts of 1906 you are hereby notified 

that the school examination of 

shows that there is some trouble with the ^^' which needs competent 
medical advice. Please attend to this at once. 

Teacher 

190 



Commonttiealtf) of Jllasisiactjusietts; 

NOTICE TO PARENT OR GUARDIAN 

In accordance with Chapter 502 of the Acts of 1906 you are hereby notified 

that 

has been examined by me as school physician and found to have symp- 
toms of 

PLEASE SECURE COMPETENT MEDICAL ADVICE AT ONCE. 

School Physician. 

190 

EYE AND EAR EXAMINATIONS AS CONDUCTED BY THE 
NEW YORK STATE DEPARTMENT OF HEALTH 

In the examinations conducted by the New York State Department 
of Health, the sight test cards are similar to the ones used in Massa- 
chusetts. As the instructions issued differ somewhat from those in use 
in the New England State, they are reproduced in full, together with 
the blank xised for notifying the parents of defects found and the head- 
ing of the blank used by each teacher for reporting the results of the 

examination in her room. 
8 



114 



Medical Inspection of Schools 



TEACHERS' INSTRUCTIONS FOR THE EXAMINATION OF 

THE EYES AND EARS OF SCHOOL CHILDREN, 

NEW YORK STATE 



NEW YORK 

STATE DEPARTMENT OF HEALTH 

ALBANY 



Teachers' Instructions for the Examination of the Eyes and 
Ears of School Children 



I — Excep- 
tions 

2-3 — General 
Directions 



4 — Abnormal 
Conditions 



5— Test for 

Normal 

Vision 

6 — Testing 

Distant 

Vision 



7 — Inability 
to Narae 
Letters 



EYES 
Children under 7 years need not be examined. 

Children wearing glasses should be tested with their 
glasses properly adjusted to their faces. 

Children should be examined singly and privately. 

Ascertain whether the child habitually suffers from 
inflamed lids or eyes or after study has weariness or pain 
in eyes or head or is suffering from squint (eyes crossed). 

Find whether the vision is normal by the large charts. 
Do not expose the charts except when they are in use, as 
familiarity leads to memorizing the letters. 

The chart should have a good side illumination and 
not be hung in range of a window which will dazzle the 
eyes. It should be on a level with the head and at a 
measured distance of 20 feet from the child, who should 
sit facing it. Examine each eye separately by holding a 
card or other screen close in front of one eye while the 
other is examined, but do not have the test made with 
one eye closed by pressvue or otherwise. Test the right 
eye first by having the letters named in order from the 
top downward. For the left eye have the letters named 
from right to left to avoid repetition from memory. 

Where the child cannot name the individual letters 
although able to read, the chart of figures may be used. 
It may also be used as a control test. If the child does 
not know figures or letters use the chart of inverted E's, 



Vision and Hearing Tests by Teachers 115 

asking the child to tell by the movement of the hand the 
side on which there is an opening in the E's in the different 
lines, i. e., up, down, right or left. 

If it is suspected that the answers are being made 8— Memoriz- 
from memory a hole about one and one-half inches may ^°S 
be cut in a narrow strip of cardboard so as to allow only 
one or two letters to show through the hole, and by 
skipping around rapidly it is easy to break up the mem- 
orizing of the letters. 

The lines on the 3 large charts are numbered 200, 9 — Recording 
100, 70, 50, 40, 30, 20. These indicate the distance the I>istant 
respective letters should be read by the normal eye. ^^^^°^ 
The record is made by a fraction, of which the numerator 
represents the distance of the chart from the child, and 
the denominator the lowest line he can correctly read. 
Thus if at 20 feet he reads the lowest line the vision is f ^ 
or normal. If he only reads the line above, the vision 
is f^ or I the normal. If he cannot read the largest 
letter he must go slowly toward the chart until he can. 
The distance he is from the chart when he can read the 
largest letter will be the numerator and 200 the denomi- 
nator. Thus, if he could not tell the letter until he is 10 
feet from the chart his vision will be ^Y^ or yV the 
normal. 

The eyes should also be tested at the near point and 10 — Testing 

separately as with the large chart, the scholar being seated ^^^^ Vision 

with his back toward the light and with the small chart °^ Focusing 

Power 
well lighted. Begin at 18 inches and steadily bring the 

chart nearer and nearer while the scholar continues to 

read aloud. When he can read no further measure the 

distance from his eye to the chart. If the child has 

difficulty in reading the chart he can spell the words, and 

the test will be determined by his failure to pronounce 

the letters correctly. 

The fractions |^, |^, ^VV, etc., will record the dis- i"g"DiJtant' 
tant vision (20 feet) of each eye. Reads right eye — and Near 
inches up to — inches ; reads left eye — inches up to — Vision 



ii6 



Medical Inspection of Schools 



inches will record the focusing power of each eye; as, 
R. E. = i6 up to 4 in.; L. E. = 15 up to 3 J in. 



I — Excep- 
tions 
2 — Directions 

3 — Abnormal 
Conditions 



4 — Testing 
Hearing 



5 — Recording 
Hearing 



EARS 
All children should be examined. 

Children should be examined singly and privately. 

Ascertain whether the child has frequent earaches, 
has pus or a foul odor proceeding from either ear, suffers 
from frequent "colds in the head," is subject to a con- 
stant catarrhal discharge from the nose or throat, or is a 
mouth-breather. 

Seat the child facing you near one end of a quiet room 
with the windows closed and begin the test of the hearing 
at a measured distance of 25 feet. The test is made by 
having the left ear tightly closed with the finger while 
you observe the ability of the child to repeat your moderate 
whispers of numbers between 21 and 99 inclusive, avoid- 
ing those with ciphers; as, 75, 55, 37, 22, etc. Test the 
left ear with the right tightly closed. Avoid having a 
wall behind you to act as a sounding board. The figures 
should have as nearly equal emphasis as possible, and 
the distance at which the child correctly repeats a series 
of 3 numbers gives his hearing distance for that ear. No 
further test is necessary if the child hears the numbers 
perfectly with each ear. If this test shows a slight 
defect of either ear, further tests may be made by observ- 
ing how the child hears the tick of an ordinary watch, 
which should be heard normally at a distance of not less 
than 3 feet. 

The hearing is recorded by a fraction of which the 
numerator represents the distance you are from the child 
and the denominator is 25. If he repeats the numbers 
correctly at 25 feet his hearing is ff or normal. If he 
only repeats the numbers correctly when you are at 20 
feet it is ff or |- the normal, and at 1 2 feet |^, etc. 



Vision and Hearing Tests by Teachers 117 

CARDS AND REPORTS 

These examinations should be made annually in i — Time 
October, and after the mid-winter examinations in the 
case of new pupils. 

All the charts should be kept without rolling or being 2— Charts 
folded, in a clean dark place to prevent the yellowing of 
the paper. 

Send at once a properly filled blank to the parent or 3 — Reports to 
guardian of all children whose vision is less than ff , in Parents or 
either eye. Do not fail to report cases where the vision Guardians 
is f ^, if the child is backward in school work, suffers ^^7® Con- 
from any abnormal condition of the lids, inflamed eyes, 
has a discharge from either eye or frequent headaches. 

Report all cases where the hearing with either ear ^ j.^ Con- 
falls below normal, or the child suffers from any of the ditions 
conditions mentioned under "Abnormal Conditions 
—Ears." 

Mail to the State Department of Health a report 4 Health 

giving the name and age of all children examined. Department 
Where the distant vision is f^, the focusing power 18 Reports 
inches up to 4 inches, and there are no abnormal condi- 
tions of the eye or lids, or headaches; and where the 
hearing is normal in each ear, without any other abnormal 
condition, leave the spaces opposite such names vacant. 

The vision and hearing are recorded in the proper 
spaces for each by fractions as explained above. All 
abnormal conditions of the eyes, lids, ears, nose, throat, 
and headaches are to be recorded by proper abbrevia- 
tions under the respective headings. 

This report must be filed with the Department 
within 10 days. 

EUGENE H. PORTER, M.D., 

Commissioner of Health 



Town. 



NEW YORK STATE BOARD OF HEALTH, 
REPORT OF TEACHER 

District 



No. 



1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
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18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
29 
30 
31 
32 
33 
34 
35 
36 
37 
38 
39 
40 
41 
42 
43 
44 
45 



Name. 



Age. 



Distant 
Vision. 
(20 feet.) 



R. E. L. E 



Focusing 
Power. 
(Inches.) 



R. E. L. E 



Eyes. 

Inflam. 
Disch. 
Squint. 



LIDS. 

Inflam. 

Scaly. 

Swollen. 



Eyes. 

Pain. 
Fatigued 
after use. 



ii8 



Schoo l. 

Head- 
ache. 

Daily 
Weekly. 



Grade. 



Hearing. 



R. E. 



L. E. 



Ear. 



Pain. 



Ear. 



Disch. 
Odor. 



Nose. 



Colds, 
Catarrh. 



Throat. 



Mouth- 
breather 



Cases 
Reported 

to 
Parents 
or Guard- 
ians. 



Gen. Health. 



Remarks. 



119 



120 Medical Inspection of Schools 

BLANK USED FOR NOTIFYING PARENTS, NEW YORK STATE 

Public School No 

190 



Mr. 



* eyes 
*son 

An examination of your daughter shows the to be defective 

■' ° nose 

throat 
and below the standard required by the State Department of Health. 
This child cannot do satisfactory work in school until this defect is 
corrected. 

You should consult with your family physician or with the health 
officer of the village as to the choice of an eye or ear doctor whom you 
are advised to consult about the trouble. 

Teacher. 

* Strike out the words not required. 

EYESIGHT TESTS CONDUCTED BY THE STATE BOARD OF 
EDUCATION OF CONNECTICUT 

Eyesight tests are conducted by the State Board of Education of 
Connecticut under the provisions of Section 2251 of the general statute. 
This section reads as follows : 

The State Board of Education shall prepare or cause to 
be prepared suitable test cards and blanks to be used in 
testing the eyesight of the pupils in public schools, and 
shall furnish the same, together with all necessary instruc- 
tions for their use, free of expense, to every school in the 
state. The superintendent, principal, or teacher, in 
every school, during the fall term in the year 1904 and 
triennially thereafter, shall test the eyesight of all pupils 
under his charge according to the instructions fm-nished, 
and shall notify in writing the parent or guardian of every 
pupil who shall be found to have any defect of vision or 



Vision and Hearing Tests by Teachers I2i 

disease of the eyes, with a brief statement of such defect 
or disease, and shall make written report of all such 
cases to the State Board of Education. 



INSTRUCTIONS 

The following instructions, prepared by S. B. St. John, M.D., of 
Hartford, give a method of intelligently making the tests required by 
the law and also indicate the form of reports to parents and the State 
Board of Education: 

Separate Test for Each Eye 

In testing the eyesight with the large chart (I), each 
eye should be tested separately, the other eye being 
covered with a screen and both eyes being open. 

Light 

The chart should be hung in a good light, preferably 
a side illumination, and not in range with a window (which 
might dazzle the eyes of the child). 

Method 

Seat the child at a measured distance of 20 feet from the 
chart and cover one eye with a pasteboard screen. Have 
him pronounce aloud the letters, beginning at the top, and 
reading from left to right, and note the lowest line that he 
reads correctly. Repeat the test for the other eye, but 
have him reverse the order and read from right to left (or 
backwards), to avoid the danger of repeating from memory. 

Record 

To record the visual power thus obtained notice that 
the lines are numbered 200, 100, 70, 50, 40, 30, and 20. 
These numbers indicate the distances at which the respec- 
tive letters should be read by a normal eye. The record 
is made by a fraction, of which the numerator represents 
the distance from the child to the card and the denominator 
the lowest line he can correctly read. Thus if at 20 feet 



STATE OF CONNECTICUT, EYESIGHT TEST, 
CHART I 

(Printed on heavy white cardboard, size 9 x 20 inches.) 



200 




100 



991 




70 





50 







40 



30 



20 m 



15 PRBOHKOF 



Vision and Hearing Tests by Teachers 123 

he reads the lowest line the vision is |^ or i = normal. 
If he only reads the line above, the vision is f ^ or § normal. 
If he cannot read the largest letter at 20 feet, he must go 
slowly toward the card until he can read the largest letter. 
The distance from him to the card (as before) will be the 
numerator and 200 the denominator. Thus, if he could 
not tell the letter until he was 10 feet from the card his 
vision = ^\, or ^V of normal. 



TEST OF FOCUSING POWER 

STATE OF CONNECTICUT, EYESIGHT TEST, 

CHART II 

(Printed on heavy white cardboard, size 6x8 inches.) 

State of Connecticut 

EYESIGHT TEST 

Chart II 

w»s born at York on the first of March In the iixth year of the reign of King Charles the First. Prom the time when 
waa quite a young child, I had felt a great wish to spend my life at sea, and as I grew, so did this taste grow more and 
miore strong ; till at last I broke loose from my school and home, and found my way on foot to Hull, where I soon got a 
place on board a ship. When we had set sail but a few days, a squall of wind came on, and on the fifth night we sprang* 
l«ak. All hands were sent to the pumps, but we felt the ship groan in all her planks, and her beams quake from stem to 
stern; so that it was soon quite clear there was no hope for her. and that all we could do was to save our lives. The first 
tiling was to fire off guns, to show that we were in need of help, and at length a ship, which lay not far from us, sent a boat 
to our aid. But the sea was too rough for it to lie near our ship's side, so we threw out a rope, which the men in the boat 
•aught, and made fast'and by this means we all got in. Still, in so wild a sea it was in vain to try to get on board the ship 
which had sent out the men, or to use our oars in the boat, and all we could do was to let it drive to shore. In the 
space of half an hour our own ship struck on a rock and went down and we saw her no more. We made but slow way to 
tk« land, of which we caught sight now and then when the boat rose to the top of some high wave, and there we 



The chart (II) of fine type is for testing the focusing 
power. In normal eyes the focusing power varies with 
age. Up to lo years the normal eye will read up to 2^ 
inches; at 12, up to 2|; at 15, up to 3, and at 20, up to 
3I. The focusing power may be affected by temporary 
conditions, and variations from the normal figures are 
important only when marked and constant. 

The eyes should be tested separately, as with the 
large chart, the scholar being seated with his back to- 
ward the Hght, but not so much as to shade the card. 
Begin at 12 inches and steadily but slowly bring the card 



CHART OF GRADUATED FIGURES, STATE OF 
CONNECTICUT, EYESIGHT TEST, CHART III 

(Printed on heavy white cardboard, size 9 x 20 inches.) 



100 




mm 




70 









40: 



fct QflRB^ 



K l-i 



30 



20 a 



1; (m 



15 623094538280 



124 



CHART OF E's, STATE OF CONNECTICUT, EYE- 
SIGHT TEST, CHART IV 

(Printed on heavy white cardboard, size 9 x 20 inches.) 



200 




100 





70 






50I1W 



30 



M Ed 



20 m m E [a a E 



15 BBS m w E m 

"5 



126 Medical Inspection of Schools 

nearer while the scholar continues to read aloud; when 
his hesitancy shows that he is not seeing correctly, 
measure the distance from his eye to the card, and 

record "Reads up to inches with R. eye." 

Repeat this test for the other eye and then for both 
eyes. 

If it is uncertain whether the hesitancy in reading 
arises from indistinct seeing or inability to pronounce 
the word, ask the scholar to tell the instant when the 
letters begin to be confused and measure the distance 
then. 

The chart of graduated figures (III) is to be used in 
cases where the scholar knows figures and does not know 
letters. 

The chart covered with E's (IV) is for those who know 
neither letters nor figures. The teacher should stand by 
the chart and point out the different characters, asking 
which is the "open side," i. e., whether it opens up, down, 
right, or left. It is better to have the scholar indicate the 
open side by a gesture of the hand in the direction corre- 
sponding to that side. The details of the use of charts 
III and IV are the same otherwise as of that containing 
letters. 

Use of Charts 

The charts should not be hung in the schoolroom 
when not in use, as the scholars very readily memorize 
them, which vitiates the examination. If the teacher 
suspects that the answers are being made from memory, 
a hole about i^ inches square may be cut near the end 
of a narrow strip of cardboard, and this may be used to 
cover the lines, exposing only one or two letters at a time 
through the hole. By skipping around rapidly with this 
device it is easy to break up the memorizing trouble. 



Vision and Hearing Tests by Teachers 127 

REPORTS 

The following are forms of reports : 



Teacher's Report to Parent or Guardian, Blank i. 



Eyesight test 
blank i 



REPORT TO PARENT OR GUARDIAN 

BY TEACHER 

Town District School 



190 . . . 

To 



You are hereby notified that the examination of the eyes of 

[name] 
shows that they are — [Here describe the condition in simple terms, whether sore, 
discharging matter, watery, or of strained appearance. If none of these conditions 
exist, cancel this section.] 



The examination of the eyesight shows that it is defective in < u„^u \ eyes. The 

defect is such that in the Right eye the sight power is ^ [give fractional form as deter- 
mined by tests] of what it should be, while in the Left eye it is ^ 

You are advised to take to a physician as soon 

as possible to ascertain what is the trouble, whether it can be remedied, and whether 

< , > should continue to go to school. 

Teacher. 



128 ■ Medical Inspection of Schools 

Teacher's Report to State Board of Education, Blank ii. 

Eyesight test 
blank ii 

REPORT TO STATE BOARD OF EDUCATION 

BY TEACHER 

Scholar 

Town District School 

190 

Name Age 

General condition of health 

General appearance of eyes [whether red, watery, or discharging material thicker 
than water], 

General appearance of eyelids [whether red, swollen, or covered with crusts], 

Results of Testing (at 20 feet with chart). 

Vision of right eye = Vision of left eye = 

Results of Testing (with small type). 

With right eye, nearest point at which the diamond type can be read is 

inches. With left eye inches. With both eyes reads up to inches 



Teacher. 



Report to State Board of Education, Blank ill. 



Eyesight test 
blank iii 



REPORT TO STATE BOARD OF EDUCATION 

BY SUPERINTENDENT, PRINCIPAL OR TEACHER 
School 

Town District 

School Department 

Number enrolled in school 

[schools] 

Number tested 

Number blanks sent to parents 



Remarks. 



Superintendent 

Date, Principal or 

Teacher 



Vision and Hearing Tests by Teachers 129 

SUGGESTIONS 

Blank i should be sent to parents only when some defect of eyesight is 
discovered by the test. No blank is to be sent when the eyesight is normal. 

When blank i is sent to parents, blank ii should be sent to the State 
Board of Education. 

When the eyesight of all pupils in the school has been tested, superin- 
tendents, principals, or teachers are requested to send to the State 
Board of Education the general blank iii showing the whole number 
of scholars tested. 

For blanks or information address 

State Board of Education, 

Hartford. 

EXAMINATIONS OF THE STATE BOARD OF HEALTH 
OF UTAH 

In Utah, cards similar to those in use in Massachusetts and New 
York are furnished for the testing of eyesight. The instructions fvir- 
nished teachers, together with a reproduction of the report blank filled 
in by the principal of the school and forwarded to the State Board of 
Health, follow. 

Instructions for the Examination of School Chil- 
dren's Eyes and Ears, etc. 

(After the Method Proposed by Dr. Frank AUport, of Chicago, 111.) 
For Use of Principals, Teachers, etc. 

Do not expose the card except when in use, as familiarity 
with its face leads children to learn the letters "by heart." 

First grade children need not be examined. 

The examinations should be made privately and singly. 

Children already wearing glasses should be tested with 
such glasses properly adjusted on the face. 

Place the "Vision Chart for Schools" (Snellen's) on the 
wall in a good light ; do not allow the face of the card to be 
covered with glass. 

The line marked XX (20) should be seen at twenty 
feet, therefore place the pupil twenty feet from the card. 

Each eye should be examined separately. 

Hold a card over one eye while the other is being ex- 
9 



130 Medical Inspection of Schools 

amined. Do not press upon the covered eye, as the 
pressure might induce an incorrect examination. 

Have the pupil begin at the top of the test card and read 
down as far as he can, first with one eye and then with 
the other. 

Facts to Be Ascertained 

1. Does the pupil habitually suffer from inflamed lids or 

eyes? 

2. Does the pupil fail to read a majority of the letters in 

the number XX (20) line of the Snellen's Test 
Types with either eye ? 

3. Do the eyes and head habitually grow weary and 

painful after study ? 

4. Does the pupil appear to be "cross-eyed"? 

5. Does the pupil complain of earache in either ear? 

6. Does matter (pus) or a foul odor proceed from either 

ear? 

7. Does the pupil fail to hear an ordinary voice at twenty 

feet in a quiet room? Each ear should be tested 
by having the pupil hold his hand over first one ear, 
and then the other. The pupil shoidd close his 
eyes dviring the test. 

8. Is the pupil frequently subject to "colds in the head" 

and discharges from the nose and throat ? 

9. Is the pupil an habitual "mouth breather"? 

If an afl&rmative answer is found to any of these ques- 
tions, the pupil should be given a printed card of warning 
to be handed to the parent, which should read something 
like this : 

Card of Warning to Parents 

After due consideration it is believed that your child 
has some Eye, Ear, Nose and Throat disease, for which 
your family physician or some specialist should be at 
once consulted. It is earnestly requested that this 
matter be not neglected. 

Respectfully, 

School. 



Vision and Hearing Tests by Teachers 

If only an eye disease is suspected, the words " ear, 
nose and throat" should be crossed off; if only an ear 
disease is s\ispected, the words "eye, nose and throat" 
should be crossed off; if it is only a nose and throat dis- 
ease, the words "eye and ear" should be crossed off. 

It will be observed that these cards are non-obligatory 
in their natiure. They do not require anything of the 
parent, who is at perfect liberty to take notice of the 
warning card or not, as he sees fit. They simply warn 
the parent that a probable disease exists, thus placing the 
responsibility upon the parent. 

Nevertheless, if parents neglect the warning thus 
conveyed, the teacher should, from time to time, en- 
deavor to convince such parents of the advisability of 
medical counsel. Teachers are urged to impress upon 
pupils and parents the necessity for consulting reputable 
physicians. 

These tests should be made annually at the begin- 
ning of the fall term, and should include all children 
above the first grade. 

Each teacher should examine all the children in his or 
her own room, and should report the results of such ex- 
aminations to the principal, such report to be signed by 
the examining teacher. 

The following simple form of report, to be filled out 
by the teacher and handed to the principal, is suggested 
and may be printed upon paper of any size and character 
that is deemed advisable by the local and school au- 
thorities, and should be distributed to the different room 
teachers : 



131 



No. 


Name of Pdpil. 


Do THE Tests Indicate an Eye, Ear, 
Nose or Throat Disease ? Answer 
" Yes " OR " No." If so, which ? 


Was the Pupil 
Given a Card of 
Warning? 


I 
2 
3 
4 


John Doe 
Robert Smith 
Mary Brown 
Edward Hart 


Yes ; eye 

Yes ; ear 

No 

Yes ; nose or throat 


Yes. 
Yes. 
No. 
Yes. 



132 Medical Inspection of Schools 

Report to State Board of Health of Utah, of Eye, Ear and 

Throat Tests 

Report to State Board of Health of Eye, Ear and Throat 
Tests of Pupils in Public Schools 



Date 

Place 

Name or Number of School 

Grade of Pupils 

Name of Principal 

Name of Teacher 

Number of Pupils in room 

Number of Pupils tested 

Nmnber of Pupils wearing glasses 

Number of Pupils free from symptoms of eye, ear, nose and throat 
disease 

Number of Pupils suspected of having defective sight or eye disease 
in addition to those v^earing glasses 

Number of pupils suspected of having defective hearing or disease 
of ears 

Number of Pupils suspected of having disease of nose or throat 

Has notification been sent to parents in each case where defect is sus- 
pected ? 

Remarks by Teacher or Principal 



Note. — This report should be mailed to the State Board of Health promptly after 
tests have been made. 



Vision and Hearing Tests by Teachers 



133 



In the city of Ogden there are three more interesting blanks used 
in connection with these tests. 

The first is the report of the teacher to the principal. 

Teacher's Report to Principal, Ogden, Utah 

TEACHER'S REPORT TO PRINCIPAL. 



No. 


Name of Pupil. 


Do the tests indicate an Eye, Ear, 

Nose or Throat Disease ? 

Answer " Yes" or "No." 

If so, which? 


Was the Pupil 

given 

a Card of 

Warning? 











































The results of examinations and tests are made known to parents 
by means of a card of warning: 



Card of Warning to Parents, Ogden, Utah 

CARD OF WARNING TO PARENTS. 

As a result of examination and tests made under instructions from 
the State Board of Health, it is believed that your child has some Eye, 
Ear, Nose and Throat disease, for which your family physician or 
some specialist should be at once consulted. It is earnestly requested 
that this matter be not neglected. 

Respectfully, 

Teacher 

Many serious consequences result from uncorrected defects of 
sight and hearing in school children, also from mouth breathing, which 
is usually caused either by an obstruction in the nose or by the pres- 
ence of adenoids. It is extremely important that defects of vision shall 
be corrected by properly fitted glasses and that any condition causing 
mouth breathing shall be promptly removed by proper treatment. 



134 Medical Inspection of Schools 

The third blank in use in the Ogden schools is of special interest 
because it is almost, if not entirely, unique among the blanks used in 
American school systems. It is a blank on which the teacher requests 
from the parent an explanation of the absence from school of a pupil 
and on which the parent writes the excuse. On the reverse are printed 
the rules governing absence and tardiness. 



Teacher's Request upon Parent for Explanation of Absence of 
Pupil, Ogden, Utah 

Ogden Public Schools 

Ogden, Utah, ..„ 190 

M -- - - 

Your— - 

has been absent from school as follows : 



for which a sufficient excuse should be given. 

Teacher 

(WRITE EXCUSE BELOW) 



Parent 

SEE OTHER SIDE 



Vision and Hearing Tests by Teachers 135 

Rules Governing Absence and Tardiness 



7. Pupils are required in all cases of absence to bring, 
on their return to school, an excuse in writing from their 
parents or guardians, assigning good and sufficient reasons 
for such absence. The only valid excuses for such 
absence are: (i) Sickness of the pupil; (2) Sickness or 
death of some member of the family requiring the presence 
of the pupil at home or making it impossible to send the 
pupil promptly; (3) Inclement weather, when sending the 
pupil would endanger his or her health. 

8. Pupils must bring written excuse from parent or 
guardian for tardiness, unless the cause of same be known 
to the teacher. Two times tardy is equal to one-half 
day's absence. 

9. For violation of any of the foregoing rules the 
principal may temporarily suspend a pupil from school 
and thereupon shall immediately inform the parent or 
guardian of the fact and the cause therefor, and also 
report the case to the Superintendent. On second sus- 
pension of such pupil for the same offense, he shall not be 
permitted to return without a special permit from the 
Board, 



The methods advocated by the State Boards of Health of Massa- 
chusetts, New York, and Utah, and the State Board of Education of 
Connecticut, by which teachers can test their pupils for defects of 
eyesight and hearing, have been described at length, because it is gen- 
erally recognized that with slight training teachers are competent to 
conduct such tests. It is even claimed that there is an advantage in 
having them made by teachers, because parents will not accept the 
diagnosis as authoritative and will consult specialists as to the alleged 
troubles found. There can be no doubt, too, that making such tests 
awakens teachers to a quickened interest in the bearing of physical 
defects on school progress, gives them a closer insight into the charac- 



136 Medical Inspection of Schools 

teristics of their pupils, and stimulates them to further work in the field 
of child study. Where no form of medical inspection exists, such tests 
by teachers certainly constitute a useful and practical first step toward 
securing such a system. It is just as certain that work done by teachers 
does not and cannot render imnecessary the services of the trained 
medical expert. 



CHAPTER IX 

Administration 

For the purpose of discussing different phases of administration, 
there may be distinguished four different classes of systems of medical 
inspection, all of them in force in different parts of the United States. 

First : Examinations for the detection of physical defects conducted 
by teachers. Such examinations are generally limited to examinations 
of vision and hearing. 

Second: Examinations conducted by physicians for the detection 
of contagious diseases only. 

Third: Medical inspections conducted by physicians for the de- 
tection of contagious diseases, combined with physical examinations 
for the detection of physical defects. 

Fourth : Systems combining the features of examinations by teachers 
for defects of vision and hearing, and examinations by physicians for 
the detection of contagious diseases and non-contagious physical defects. 

Obviously, examinations of the first sort, that is, examinations 
conducted by teachers for the detection of defects of vision and hearing, 
are by far the least expensive. Such systems have been discussed at 
length in Chapter VIII. They are prescribed by state law in Massa- 
chusetts, Vermont, and Connecticut ; and have been or are being 
conducted without specific legal enactment in some other states, 
notably New York, California, and Utah. 

The only expenses incurred in conducting such examinations are 
for printed material, consisting of rules of instruction, test cards, record 
blanks, notification cards, etc. Even for a large number of children 
the expense is low. The Massachusetts statute has the following sen- 
tence in Section 6: " The State Board of Education may expend during 
the year nineteen hundred and six a sum not greater than fifteen hundred 
dollars, and annually thereafter a sum not greater than five hundred 
dollars, for the purpose of supplying the material required by the act." 

137 



138 Medical Inspection of Schools 

In Massachusetts all the material used by teachers for the tests is sup- 
plied by the State Board of Education to all teachers. There are 
slightly over half a million pupils enrolled in the public schools of 
Massachusetts. At an annual cost of five hundred dollars, this means 
that the tests cost approximately one-tenth of one cent per pupil. The 
time necessary to conduct them is from three to five minutes per 
pupil. Thus it will be seen that both in time and in money the 
necessary expenditure is slight. 

As has aheady been explained, such tests do not take the place of 
thorough examinations by competent, trained experts. That they are 
of great and real value, however, is not to be gainsaid ; and it is greatly 
to be doubted if in the whole range of educational endeavor there can 
be discovered another field where so great returns for good are to be 
secured at so small an expenditure of time and money. 

The second sort of medical inspection, that which has for its object 
to discover incipient cases of infectious diseases and by their removal 
from school to prevent the disease from becoming epidemic, is in reality 
merely an extension of the work which has been done by boards of 
health. It is, of course, not expensive. In most cities the doctors 
call every day or at least several times a week, and look over all the 
children referred to them by the teachers as seeming to be in ill health 
or who have returned to school after an unexplained absence. Chicago 
employs one hundred doctors under the Board of Health to do this work. 
The system was in vogue in New York for a number of years. Before 
the passage of the medical inspection law, many cities of Massachusetts 
had it. It is still the most common system in this country. 

Under this plan the method of sending for the doctor varies in 
different towns. Usually in cities he comes at stated times without 
being notified, knowing that he is sure to find some children waiting 
for him to examine. In some places the principal hangs out a card 
as for the ice man, and the doctor, making his daily rounds, notices it 
and stops. A common method is for the principal or superintendent 
to notify the doctor by telephone. 

The third system combines with the inspections for contagious 
diseases a purpose much more fundamental in its character and likely 
to be more far-reaching in its influence. This purpose finds expression 
in physical examinations to ascertain whether the pupil is suffering 



Administration 



139 



from defective sight or hearing, or from any other disability or defect 
tending to prevent his receiving the full benefit of his school work, or 
requiring a modification of the school work in order to prevent injury 
to the child or to secure the best educational results. 

This system probably finds its highest exemplification in the schools 
of New York City. It is, of course, a much more expensive form of 
medical inspection than either of the other two systems described. It 
requires the employment of skilful physicians for considerable periods 
of time. It is a much more serious matter to make a fairly complete, 
even if somewhat superficial, physical examination of a child than 
merely to decide whether or not a child shows symptoms of some conta- 
gious disease. With a like expenditiu-e of time, it is impossible for a 
doctor to look out for as large a number of children tmder this system 
as under the preceding one. 

Of the worth of the complete physical examination there can be no 
doubt. The only disadvantage which can be alleged against the 
system is that it often results in divorcing the work of the medical 
examiners from the interests of the teachers and the school authorities. 
This is mainly a difficulty of administration, rather than inherent in 
the system, and can largely be overcome. 

The foiirth system, that of having teachers examine for vision and 
hearing, and physicians for contagious diseases and physical defects, 
is the one prescribed by the Massachusetts law. It is also in use in some 
places outside of that state, notably in the city of Los Angeles, California. 
It has the advantage of enlisting the interest and cooperation of the 
teachers, while utilizing the trained knowledge of the physician. 



SALARIES OF MEDICAL INSPECTORS AND THE NUMBER 
OF PUPILS PER INSPECTOR 

The foregoing description of the different systems of medical in- 
spection has been necessary in order to discuss the question of salaries, 
on account of the great variation in different localities as to the work 
performed and the remuneration received. The following table gives 
the facts in regard to the number of inspectors, salaries, number of 
children per inspector, and per capita cost for salaries for seventeen 
cities: 



140 Medical Inspection of Schools 

FACTS IN REGARD TO MEDICAL INSPECTION IN 
SEVENTEEN CITIES 



City. 


State. 


Average 
Attend- 
ance. 


Medical 
Inspectors. 


Children 

Per 
Inspector 


Salaries 
OF In- 
spectors. 


Total 

op 

Salaries. 


Per 

Capita 

Cost foe 

Salaries 

Only. 


Boston 


.Mass.. 


. 86,839 


80 


1085 


$200 


$16,000 


$.184 


Brockton. . 


.Mass. . 


. 7,781 


7 


iiii 


200 


1,400 


.179 


Camden . . 


.N.J... 


- 9,718 


I 


9718 


2400 


2,400 


.247 


Chelsea . . . 


. Mass. . 


- 6,047 


3 


2015 


200 


600 


.099 


Detroit ... 


.Mich. . 


• 37,757 


27 


1398 


250 


6,750 


.178 


Lawrence . 


.Mass. . 


• 7,530 


I 


7447 


1500 


1,500 


.201 


Montclair . 


.N.J... 


• 2,503 


4 


625 


305 


1,220 


.487 


Newark.. . 


.N.J... 


. .38,562 


16 


2410 


400 


6,400 


.165 


New Haven Conn. . 


- 18,135 


5 


3627 


240 


1,200 


.066 


New York. 


.N. Y. . 


.523,084 


166 


3151 


1200 
' I at 


199,200 


.380 


Paterson . . 


.N.J... 


- 15.238 


3 


5168 ■ 


1500 
sat 
■ 1200 - 
I at 1 


3,900 


.251 


Seattle 


.Wash.. 


• 16,174 


II 


1470 • 


1200 
10 at 
600 ■ 


7,200 


•445 


Somerville. 


.Mass. . 


. 11,166 


7 


1581 


200 


1,400 


.126 


Springfield. 


. Mass. . 


. 10,605 


II 


964 


250 


2,750 


•259 


Woonsocket R. I. . . 


. 2,862 


6 


477 


5° 


300 


.104 


Worcester . 


.Mass. . 


- 18,273 


IS 


1218 


200 


3,000 


.164 



A number of considerations are necessary to the understanding of 
the table. In the first place, the expense for salaries of inspectors is 
not the whole expense for medical inspection. In all of the cities ex- 
penditures for printing and incidentals are necessary, and in Boston 
and New York there is the very considerable added expense for paying 
large corps of trained nurses. It is further to be remembered that the 
inspectors in New York receive their salaries at $100 per month in 
return for their services as district physicians of the Board of Health 
and that their duties as school physicians constitute only a part of their 
work. Again, in cities where a considerable number of inspectors is 
employed, they are under the supervision of chief inspectors who receive 
higher salaries. These salaries do not appear in the table. Still 
another consideration is that in most of these cities the doctors conduct 



Administration 141 

examinations for the detection of contagious diseases only, while in a 
few they make the much more exacting physical examinations and 
consequently fewer of them. In short, conditions vary so that they 
are not comparable on a basis of equaHty in any two cities. 

Bearing the above considerations in mind, a study of the table becomes 
possible. The number of children per inspector varies from 477 in 
Woonsocket, R. I., to more than twenty times that number, or 9,718, in 
Camden, N. J.; but the Woonsocket inspectors receive an annual 
remuneration of $50 per year apiece, while the inspector in Camden 
receives $2,400. These two cities also mark the extremes in the size 
of salary paid. ^In the matter of the per capita cost for salaries, how- 
ever. New Haven, Conn., stands at the foot of the list, with an expendi- 
ture of 6.6 cents for each pupil, and Montclair, N. J., at the head with 
one of 48.7 cents per pupil. 

Of course, many cities having systems of medical inspection do not 
appear in the table, and some of them represent still greater extremes. 
In many places the work is carried on by volunteer workers without 
remuneration. The towns of Shelburne and Littleton, Mass., pay their 
school physicians $25 per year. The committee appointed by the 
School Board of Harrisburg, Pa., to investigate and report on medical 
inspection reported in April, 1908, that twenty-four cities replied to their 
questions as to the per capita cost of medical inspection. The answers 
ranged from $.005^ to $1.22. 

These facts and considerations lead to the conclusion that there 
has not yet been adopted in this country any recognized basis for the 
equitable remuneration of the services of the school physician. One 
thing seems certain — that the almost universal tendency is to so under- 
pay this work as to give the whole movement an appearance of trivi- 
ality and fail to attract competent and experienced men of the medical 
profession. There can be no doubt of the validity of the opinion 
expressed by Professor Osier in speaking of the work of medical inspec- 
tion in England: "If we are to have school inspection, let us have 
good men to do the work and let us pay them well. It will demand a 
special training and a careful technique." It is certainly to be regretted 
that this point of view has not been more generally taken in America. 

That the words of the eminent Oxford professor were heeded in 
his own country seems evident from the salaries paid to the medical 



142 Medical Inspection of Schools 

inspectors of schools in England. Almost without exception the ten- 
dency is to pay much higher salaries than in America and to make 
much more liberal provision for clerk hire and for meeting incidental 
expenses. Apparently by common consent the whole movement has 
been placed upon a higher plane than in the United States. The 
English law has but recently been put into operation, and the English 
newspapers have contained many accounts of the meetings of coimty 
councils where the new organizations were discvissed and salaries 
decided upon. It is both interesting and instructive to note the results 
of some of these meetings. 

In Northampton two inspectors have been appointed at salaries 
of $1500 apiece per year. In North Cumberland County it is estimated 
that there are 11,500 children to be examined. To do this work, 
two medical inspectors — one a man and the other a woman — have 
been appointed. They receive $1200 apiece, besides travelling expenses, 
and a clerk has been appointed to do the clerical work. ' An amendment 
introduced for the purpose of paying the woman doctor less than the 
man was defeated. The County of Guildford has employed a chief 
medical officer at $3000, to be increased by annual increments to $4000, 
and four assistants who are to receive $1 250 each. Each of these officials 
receives in addition $200 for travelUng expenses. Stafford employs a 
senior medical officer at $1515 and three jimior women inspectors at 
$1250, to be increased by annual increments to $1500. These officers 
also receive $2.00 for subsistence for each night they are forced to 
spend away from home. They are also supplied with a clerk who 
receives $405. In the West Riding District it is estimated that there 
are 50,000 children to be examined. The total cost of this work has 
been calculated at $25,000. Of this sum, $17,500 is to be devoted to 
salaries, $4000 to expenses, and $1000 to equipment. Many advertise- 
ments have appeared in The Lancet of young surgeons with some 
experience in children's hospitals who are willing to imdertake the 
work at salaries ranging from $1250 to $4500 per year. 

It is to be remarked, too, in considering these English salaries that 
the amoimts paid represent relatively greater salaries than would the 
same sums in America. The English law also requires but three ex- 
aminations in the course of the school life of the child, whereas the 
statute of Massachusetts, where the standard salary of a school physician 



Administration 143 

is $200 per year, requires that such a complete physical examination 
of each child be made every year. 

In view of the differences of the v^ork locally and the great variations 
of the conditions under which medical inspectors work in different 
localities, it is impossible to lay down any rule as to the proper number 
of pupils for each inspector. Assignments of schools to inspectors 
should be governed by the consideration of such local conditions as the 
distances separating schools, the size of the schools, the age of the 
children, and whether or not the work presents special difficulties, 
such as, for instance, foreign race and nationality of the children. 

Moreover, it is evident that the greater the number of children for 
each inspector, the less intimate will be the knowledge he has of the 
individual children. Where examinations are conducted for the de- 
tection of contagious diseases only and doctors examine only those 
children referred to them by the teachers as being suspicious cases, 
it is pretty generally the opinion that the proper number is two, three, 
or even four thousand children per doctor, depending largely on the 
distances to be travelled to reach the schools. In school systems where 
school physicians conduct formal physical examinations, besides in- 
specting for the detection of contagious diseases, it is not uncommon 
to have them work three hours each forenoon, from nine to twelve. 
Under these circumstances they receive, of coiuse, much higher remuner- 
ation than under the system just mentioned, and can attend to fewer 
pupils. Dr. John J. Cronin, Assistant Chief Medical Inspector of the 
New York City Board of Health, is of the opinion that under these 
circumstances there should be one medical inspector and one nurse 
for each two thousand pupils. Where the doctors make physical 
examinations, the fact that each examination requires from twelve to 
fifteen minutes on the average must be used as a basis for deciding on 
an equitable remuneration, according to the local rates of remuneration. 
In smaller places where the doctors visit the schools only upon the 
request of the principal or superintendent, it is sometimes customary 
to pay them at the local rate per visit, considering the whole school as 
one patient. 

New York pays its nurses $75 per month and employs them for 
twelve months in the year. Boston pays the supervising nurse $924 
for the first year, which is increased by an annual increment of $48 



144 Medical Inspection of Schools 

to a maximum of $iii6. The assistant nurses receive $648 per year 
and an annual increase of $48 \mtil the maximum of $840 is reached. 
New Haven pays its nurse $600 per year. 

In both England and Germany arrangements are often made in 
regard to payments for medical inspection which might well be studied 
with a view to their introduction in America. In England it is not 
imcommon to pay according to the work done, rather than to decide 
on any fixed amount. Thus physicians in Derbyshire submitted an 
estimate to the County Council for conducting physical examination 
of pupils at the rate of 2 s. 10 d. per head; in Worcestershire the price 
agreed upon was i s. 8 d. per head. In the County of Somerset the 
physicians receive i s. 3 d. for each pupil in the rural districts and i s. in 
the urban districts. In the North Riding and Yorkshire Districts the 
arrangement is that the medical officer shall receive i s. per child for 
physical examinations, with the addition of £1 a school in rural districts. 

In "The Medical Inspection of Schools in Germany" {'' Das Schul- 
artzwesen in Deutschland"), Dr. Paul Schubert has the following to 
say regarding the salaries of school physicians : 

"As to the salaries of school physicians there are two 
methods — a fixed salary and payment according to work 
done. In many cities there is a combination of the two 
systems, that is, a certain addition is made to the fixed 
salary. For instance, in Wiesbaden the fixed salary of the 
school physician is 600 marks and a special remuneration 
is made for the examination of all children in their first, 
third, fifth, and eighth years of school life. In Leipzig 
the fixed salary is 300 to 500 marks, according to the size 
of the district, and an additional sum of 200 marks is 
paid for the examination of pupils entering school. In 
Aix-la-Chapelle each school physician receives out of 
the total appropriation of 6000 marks a fixed salary of 500 
marks; the remainder is divided among the physicians 
at the end of the year, according to the number of children 
that each physician has examined." 

" In Mannheim the system of medical inspection is upon 
an altogether different basis. There one school physician 



Administration 145 

is in general charge (precluding private practice) with a 
salary of 10,000 marks. We await results of this arrange- 
ment." 

A feature of the financial administration of medical inspection which 
has received adequate attention abroad, but which has been almost 
entirely neglected here, is that of furnishing medical inspectors with 
adequate clerical assistance. In the nature of the case, the work requires 
the making of a great many entries on individual record cards or sheets ; 
and upon the thoroughness and system with which it is done depends 
to a large degree the efficacy of the work. Recent careful timing of 
work done by one of the most skilful examiners in the employ of the 
New York City Board of Health shows that it took him on the average 
about twelve minutes to make each physical examination. Almost 
exactly half of this time was employed in conducting the examination 
itself and the other half was spent in the purely clerical work of entering 
results on the sheets. The very writing of the names of the pupils on 
their individual record cards and those of the parents on notification 
postal cards often consumes a great deal of time in some quarters of 
the city, and constitutes a class of work which ought not to be foisted 
on to a trained physician. Here are some names taken more or less 
at random from the school registers in a Polish section : 

Rzemieszkievicz, Klymezynski, 

Zdrojewski, Wrzesimski, 

Gorzelanczyk, Guleszecwicz. 

When a doctor is being paid at the rate of from one dollar to two dollars 
per hour, it is certainly a most unbiisinesslike and inefficient policy to 
require him to spend half of his time doing work which a clerk at twelve 
or fifteen dollars a week could perform equally well. The doctor in 
question said in answer to a query that he felt sure he could examine 
twice as many children in the given time if he had the help of a clerk 
and that he would find the work much more agreeable. This is a matter 
which demands attention wherever systems of medical inspection are 
to be installed. It is at present one of the weak points of all American 
systems. 

It is very difficult to gather reliable information as to the general 



146 Medical Inspection of Schools 

expenses of medical inspection outside of the matter of salaries in Ameri- 
can cities. Apparently in most places no careful account has been kept. 
The expenses for printing, incidentals, etc., in connection with medical 
inspection have simply been included with the general expenses of the 
board of health or board of education. In only a few cases is informa- 
tion available. In Springfield, Mass., the average attendance of the 
public schools is 10,605. The expenses for medical inspection for the 
year 1907 were as follows : 

MEDICAL INSPECTION OF SCHOOLS, SPRINGFIELD, MASS. 

Receipts. 
By appropriation $2000.00 

Expenditures. 

Salaries of inspectors $1970.00 

Printing 25.15 

Postage 4-00 

Total payments 1999.15 

To contingent account .85 

$2000.00 



Montclair, N. J., has an average attendance in its public schools 
of 2,503. The following is an account of the expenses for the medical 
inspection for the school year ending December 31, 1907: 

MEDICAL INSPECTION OF SCHOOLS, MONTCLAIR, N. J. 

Receipts. 

On hand Jan. i, 1907 $1018.60 

Appropriated by Town Council 1750.00 

; $2768.60 

Expenditures. 
Salary of inspectors, Jan. i to Jxily i , 1907 . 990.00 

Salary of inspectors, July i to Dec. 31,1907 660.00 

1650.00 

Supplies Jan. i to July i, 1907 21.20 

Supplies July i to Dec. 31, 1907 47-93 69.13 

$1719.13 
Balance on hand Jan. i, 1908, to carry till July i, 1908 io49-47 

$2768.60 



Administration 147 

In decided contrast to these meagre appropriations, and showing 
that the EngUsh policy is as much more adequate than the American 
in the matter of appropriations for incidentals as in that of salaries, 
is the estimate of cost of medical inspection at East Sussex, England. 
The district contains 176 schools and approximately 26,000 pupils, 
of whom 21 per cent., or 5,460, are to be examined the first year. The 
following is a financial estimate of the subcommittee of the East Sussex 
Education Committee: 



MEDICAL INSPECTION OF SCHOOLS, EAST SUSSEX, 
ENGLAND 

Salaries and travelling expenses $3547.80 

176 weighing machines at $6.06 each 1066.56 

176 height measuring standards at 84 cents each 147-84 

360 copies Snellen's test at $2.40 per doz 72.00 

176 screens at $2.40 each 422.40 

15,000 cards at $4.86 per thousand 73-9o 

240 card cabinets 437-40 

15,000 notices to parents at $2.43 per thousand 36.4S 

Sundries 607.50 



Total for appliances and incidentals $2864.05 

Total cost for first year $641 1.85 

There are many other minor questions of administration which 
present themselves for discussion. Some of these are: Is it better 
to have medical inspectors devote their entire time to the work, or is it 
preferable that they give only part of their time and have outside prac- 
tice? Should the doctor be allowed to prescribe for children? What 
should be done in the case of parents too poor or too indifferent to take 
measures recommended by the physicians ? If, for instance, the child 
has defective vision and glasses are needed, who is to ftirnish them 
if the parents fail to do so? 

It is difficult to answer these questions because in many, if not 
most, cases the answer depends on local conditions. It is the general 
opinion of the best authorities that medical inspectors should not devote 
their whole time to the school work. The work is exceedingly monoto- 
nous, and if the doctor is prohibited from having an outside practice 



148 Medical Inspection of Schools 

opportunities for increasing his skill and enlarging his experience are 
to a great extent cut off. 

To the question as to whether a doctor should prescribe for children, 
the answer must be made that under no conditions should he lay himself 
open to the charge that he is using his official position for the purpose 
of enlarging his private practice. This is the basis for the almost 
invariable rule that except in cases of emergency the school doctor 
shall not prescribe. 

It has been suggested that in cities of small size and in towns there 
should be employed one man, a physician, thoroughly trained in the 
science of modern preventive medicine, who should fill the offices of 
school medical inspector, director of physical training in the public 
schools, and director of physical training in the playgrovmds during 
the summer months. By such an arrangement a salary could be paid 
that would attract the best men, without undue burden on the tax- 
payers, even in comparatively small places. 

The problem of furnishing free eyeglasses for indigent pupils has 
been widely discussed. As far back as 1901 the city of Cleveland 
gave away 400 pairs to pupils needing them and whose parents claimed 
to be unable to meet the necessary expense. In a number of cities first 
class opticians have made offers to furnish glasses at a uniform price 
of $1 a pair to school children. A case in point is Lowell, Mass. 

In Philadelphia there is a city ophthalmologist who prescribes for 
children found to have defective vision, and then glasses are furnished 
through his office at the cost price of eighty-five cents a pair. 

In most places where the matter has been carefully studied it is 
found that careful follow-up work on the part of the school authorities 
will result in nearly all of the cases being taken care of by the parents 
of the children, and in the cases of families genuinely unable to meet 
the expense it has always been possible to arrange with charitable 
organizations to furnish the glasses. The percentage of cases where 
this has been found necessary or desirable is exceedingly small. 

In summing up the problems of administration which relate to expense 
it can only be said that in this, as in all other branches of organized 
endeavor, cost varies with the extent and kind of work done. Examina- 
tions by teachers for the discovery of defects of vision and hearing 
involve only the added expense of the simple printed material required. 



Administration 149 

Inspection by physicians for the detection of contagious diseases is 
inexpensive and of great value in its results. 

Systems of medical inspection which include careful physical ex- 
aminations of all children cost the most and are by far the most valuable. 
From a social and economic viewpoint they are by far the cheapest 
in the better sense of the word, as they are the most far-reaching both 
in their immediate and in their indirect results. 

If, however, a system of medical inspection is to be efficient and 
effective for any considerable length of time, it is clear that adequate 
salaries must be paid to those in charge of the work. 

Efficient work can not long be expected from volunteers, and perhaps 
even less will it be given by physicians who receive a bare pittance 
in return for their time and skill. Neither can it be expected that 
first-class men will long be content to spend most of their time in doing 
the purely clerical work of filling out blanks in duplicate and triplicate. 

Permanent efiiciency will require skilled workers, careful adminis- 
tration and adequate remuneration. 



CHAPTER X 

Controlling Authorities 

Under American systems of municipal government, the question 
as to whether medical inspection of schools is a proper function of the 
board of education or the board of health is bound to arise as soon as the 
organization of such a system is contemplated. Both sides of the 
question are certain to be warmly argued. 

On the side of the board of health is the argument that the machinery 
of government already existing for the conservation of the health of 
the community may properly be extended to include new activities, 
and that another branch of the government should not duplicate social 
machinery already existing. It is further argued that an important 
feature of the medical inspection of schools is the detection and segrega- 
tion of cases of contagious disease. This is a protective measvire re- 
lating to the safety of the whole community, and as such should remain 
a function of the board of health. 

On the side of the argument for keeping the work in the hands of 
the board of education it is claimed that the whole work, to be effective, 
must be so closely related to school work and school records that friction 
inevitably results when those in charge are in the employ of an outside 
body, neither responsible to nor perhaps in sympathy with those having 
schools in charge. This results in a loss of efficiency. 

The further claim is made, and substantiated by referring to records 
of work done in many cities, that the exclusion of cases of contagious 
disease is after all a comparatively small part of the work of medical 
inspection, even where the work is confined to the examination for the 
detection of cases of contagious disease and physical examinations 
are not made. Thus in Haverhill, Mass., in 1907 the total exclusions 
amounted to 222 in a school membership of 5230, or about 4 per cent. 
In Newark, N. J., in the same year the exclusions were 1579 in a school 

150 



Controlling Authorities 151 

membership of 38,562, or again 4 per cent. In the State of Massa- 
chusetts in 1907, towns and cities having an average attendance of 
342,000 reported something more than 15,000 exclusions during the year. 
Again the percentage is 4. In all of these cases a large proportion — in 
fact nearly half of the exclusions — are on account of one cause, pedicu- 
losis (lice). In cities where school nurses are employed, these cases 
are not excluded and thus the number of exclusions is greatly cut down. 
In New York in 1906 the exclusions amounted to 11,101 among a 
school membership of 505,000, or only 2 per cent. 

A good idea of the feeling of those in charge of the work in localities 
where the question as to administration has been raised may be gained 
from reading some extracts, mostly taken from official reports, made 
by executive officers. 

In his report for 1907, Dr. William H. Maxwell, City Superinten- 
dent of Schools of New York, says : 

"Dual responsibility in the school — that of the Board 
of Education and that of the Department of Health — 
always has resulted and always will result in confusion 
and inefficiency in the work effected. It is owing to this 
dual responsibility that the large annual appropriation 
made by the city for the physical examination of school 
children is to a great degree wasted. Efficient service 
will be obtained only when the Board of Education is 
made solely responsible for all the work that goes on in 
the schools. 

"The physicians employed by the Board of Health do 
not perform any of the functions which it is highly advisa- 
ble should be performed by a truly educational department 
of hygiene, such as studying hygienic conditions in the 
schools and advising teachers regarding the pedagogical 
treatment of children in cases of fatigue and nervousness. 

"The nurses employed by the Department of Health 
have done good work in visiting the homes of sick children, 
in giving advice and assistance to mothers, and in looking 
after slight ailments in the school. The fact, however, that 
they are tmder the control of an outside organization is a 



152 Medical Inspection of Schools 

constant hindrance to their work. It is another instance 
of the evil effects which arise from dual control or divided 
responsibility. I risk nothing in saying that the school 
nurses would do much more and better work if they were 
made responsible to the educational authorities." 

Dr. Thomas F. Harrington, of the Department of Hygiene, Boston, 
says in speaking of the system of medical inspection by physicians 
in the employ of the Department of Health: 

" The greatest criticism against this system of inspection 
is that it lacks uniformity; that it excludes pupils, and 
does not provide any means of 'follow up' nor any guar- 
antee that the child will receive medical care; that the 
duties of the inspector as an agent of the Board of Health 
bring him in contact with much contagion in the homes; 
and finally that the dual duties and divided responsibility 
are not conducive to the best in the health and efficiency 
of school children." 

In speaking of the work of the school nurses, he says: 

" It does not seem possible to conceive a more satisfac- 
tory arrangement, nor a more effective piece of school 
machinery than nurses under school supervision. With 
a corps of medical inspectors under this same supervision, 
who would conduct a daily clinic in their respective school 
districts, there are no problems connected with the health 
and efficiency of school children which could not be quietly, 
rationally, economically and effectually solved. Until 
such an organization is perfected in part or in whole, 
little progress can result from the efforts to promote the 
health and efficiency of our school children." 

The Superintendent of Schools of Boston in his twenty-seventh 
annual report, July, 1907, says in regard to the Massachusetts law 
making medical inspection compulsory : 



Controlling Authorities 153 

"In this connection it should be stated that while the 
school physicians were concerned solely with contagious 
diseases, they were properly to be controlled by the Board 
of Health. Under the new law, the work of examining into 
any defect that interferes with the progress of the children 
in school is not in the main a question of public health. 
It is rather an educational question and is so directly 
allied to the work of the Department of Physical Training 
that the school physicians should be appointed by the 
school board and become a part of this department. 
The highest efficiency will be impossible until this action 
is taken." 

The Superintendent of Schools of Cleveland says in his report 
for 1907, after making an able plea for the establishment in the schools 
of the city of a system of medical supervision: 

"While it has been suggested that the kind of service 
here treated should be performed by the Board of Health, 
it is the belief that medical supervision is peculiarly a 
function of the Department of Physical Training and 
School Hygiene, and that the Board of Health's relation 
to the schools should relate to the matter of communicable 
disease." 

In his report for 1907, the Superintendent of Schools of Newark, 
N. J., says that the medical inspection as conducted by the Board of 
Health has been satisfactory, but adds that the only objection that can 
be raised against it relates to the executive control of the staff of medical 
inspectors. He says: 

"By additions to the staff, the number of medical in- 
spectors now employed in the schools is 16. The direction 
and control of this large number requires some one who 
can give more time to it than is possible for the busy and 
overworked, but exceedingly efficient, health officer. 
It seems hardly fair to impose upon him in addition to 



154 Medical Inspection of Schools 

his other duties the duty of overseeing daily the work of 
sixteen medical inspectors. 

Dr. Fred S. Shepherd, Superintendent of Schools of Asbury Park, 

N. J., says: 

"Again, if the system is to work harmoniously, the 
medical inspector shoidd work under the direction of the 
Superintendent of Schools, as do the teachers. If the 
medical inspector should regard himself as not called upon 
to accept any suggestions whatsoever from the school 
officers of administration, such as superintendents or 
school principals, it is plain that friction might arise. In 
this connection we should not overlook the fact that 
medical inspectors are human and have a few of the 
faults common to humanity. It is possible for them, as 
it is for teachers and others higher in authority, to slight 
their duties or to perform them in an inefficient and un- 
satisfactory manner. School boards are not able to pass 
judgment upon these inner workings of the system, and 
somebody should have the responsibility for holding even 
medical inspectors, if necessary, to the letter if not to the 
spirit of their obligations." 

It is to be noted that Superintendent Shepherd is speaking, not from 
the point of view of the theorist, but from that of one experienced with 
the workings of a school system, having a successful system of medical 
inspection under physicians appointed by the Board of Education. In 
telling of the workings of this system in actual practice, Dr. Shepherd 
goes on to say : 

"It has been suggested in some quarters that medical 
inspection of school children should be one of the functions 
of the local board of health, in order to prevent clashing 
of authority. As boards of health are organized in our 
own State, however, I can see no likelihood of such cross 
piurposes. I presume it does devolve upon local boards 
of health to inspect for sanitary purposes all public build- 



Controlling Authorities 155 

ings, including the public schools. This, I judge, is also, 
or should be, one of the duties of the medical inspector. 
To have the public schools inspected intelligently by two 
such departments seems to me a good thing. What one 
might overlook, the other might see. Aside from this ap- 
parent overlapping of jurisdiction, I see little opportunity 
for any clashing of interest. On the contrary, it is possi- 
ble for the very closest relations to be established 
between boards of health and the school medical au- 
thorities. How it might be in other cities of the State, I 
am not aware; but in the city of Asbury Park every case 
of contagious or infectious disease is reported immediately 
by the Board of Health to the school authorities, and vice 
versa." 

That the fears expressed by Dr. Shepherd are not imaginary is 
shown by experience in cities where the dual system of control is in 
practice. 

Such an example comes to light in the city of Lawrence, Mass. 
There medical inspection is, of course, conducted xmder the provisions 
of the State statute, which provides for the appointing of school physi- 
cians by either the school committee or the board of health. In Lawrence 
the threatened conflict came to a head in August, 1907, when the Board 
of Health appointed five physicians to inspect both public and private 
schools. By an order of the School Committee the principals and 
teachers were forbidden to extend official recognition to any but Dr. 
Bannon, who was appointed by the School Committee in August, 1906, 
for a term of three years. This continues and the schools are under a 
double inspection, with much consequent unavoidable friction. 

One of the strongest arguments in favor of medical inspection under 
the authority of boards of education is that the efficiency of the work 
demands that there shall be the closest cooperation between the medical 
and the educational authorities. If the results of the work are to be 
profitable, if diligent effort is to be made to correct the defects fovmd, 
if the physical conditions brought to view are to be used for the guidance 
of the teacher in the class-room, then certainly such intimate relation- 
ships are essential. 



156 Medical Inspection of Schools 

It has been claimed that where the work is done by the board of 
health this is dij6&cult or impossible. Certainly an examination of the 
annual reports of some of the superintendents of cities where the medical 
inspection is conducted by the board of health would seem to indicate 
that the educational authorities know little of the work that is being 
done, and so regard it as of slight importance as a guide in the work of 
the class. Examples of such an attitude as this are foimd in reports 
of the Superintendents of Schools of Haverhill and Springfield, Mass., 
for 1907. The Superintendent of Schools of Haverhill, Mass., disposes 
in his report of the work of medical inspection with the following brief 
remarks : 

"The school physicians have continued their work on 
the same basis as last year, under appointment from the 
Board of Health. I am permitted to make the following 
summary of such portions of their work as admit of classi- 
fication. A large proportion, perhaps the largest portion 
of their work, is not such as can be shown in the form of 
statistics." 

Then follows a brief list of the diseases noted by the school physicians 
and of the statistics concerning vaccination. No details are given, 
nor is there any mention made even of the number of pupils examined. 
The report is confined to some ten lines. Such comment certainly 
does not seem to indicate intimate knowledge of the work being done 
or any intimate relationship between the work of the school physicians 
and that of the educational authorities. 

A similar condition seems to be revealed in Springfield, Mass., 
where the sole comment of the School Board on the work of the physi- 
cians appointed by the Board of Health is, "So far as we can learn, 
the inspectors are fulfilling their requirements and parents generally 
follow the advice given." 

In Massachusetts medical inspectors are appointed in some of 
the cities by the boards of health and in others by the school committees. 
After watching the operation of the two systems for more than a year 
under the State law, Secretary George H. Martin of the State Board of 
Education writes: 



Controlling Authorities 157 

"The movement now in progress, which has reached 
different stages in different countries, seems to be shap- 
ing itself so as to include as necessary features the follow- 
ing elements : 

"(i) Physicians. A sufficient number of trained 
physicians to carry on the necessary examinations and 
exercise the needed oversight of all the children in the 
public and private schools, these physicians to act under the 
direction of the local educational authority, but in coopera- 
tion with local health authorities. In the larger cities the 
physicians should act under the immediate direction of a 
chief medical officer, who should be a permanent member 
of the educational staff." 

In Chapter I we have already traced the two sources of the move- 
ment that is leading to the medical care of school children; one develop- 
ing from the standpoint of existing and recognized functions of the 
Department of Health, and the other from a less well defined or con- 
scious relation of departments of education to the welfare of school 
children. The relation between these two functions is not an easily 
defined one. The fact that from a number of cities the percentage 
of cases needing exclusion is not over 4 per cent., while the number of 
children needing care with reference to defects, exercise, suitable seats 
and desks, type, paper, suitable hours of study, and the like, include all 
the children, shows that one is specific and limited, the other general 
and almost unlimited in its scope. 

It is natural that those who have approached the problem from the 
standpoint of contagious disease or pathology are prone to regard the 
whole work as belonging as a natural function to the department of 
health. It is equally natural that those who are accustomed to look 
at growth and development as the ultimate object should fail to recognize 
the fundamental obligation supported by legal powers possessed by 
the boards of health with reference to community protection. This 
legal power and obligation cannot easily be transferred to any other 
city department, and should not be, even if it could. 

In summing up, then, we may conclude as a result of the evidence 
presented : 



158 Medical Inspection of Schools 

I. The detection of contagious diseases in the schools, 
involving daily visits and the power of the law, is in the 
nature of an extension of the powers heretofore exercised 
by boards of health; and where medical inspection is to 
include nothing more than this work, systems may well be 
administered by boards of health, if care be taken to 
establish and maintain sufficiently close and friendly 
relations with the school officials. 

II. Those activities which have to do with the child's 
physical condition as related to his school work — seating, 
exercise, hours of home study — that is to say all functions 
of the medical inspection of schools except those pertaining 
to contagious diseases— rare in the natiu^e of the case an 
integral part of school interests and must not be divorced 
from them. Moreover, the records of the examinations 
of school children for physical defects likely to interfere 
with proper growth and education must, if they are to serve 
their end, follow the child from grade to grade and from 
school to school, and each case must be followed up 
constantly; that is, they are an important part of the school 
records and must be so made and administered. 

In brief: 

(a) Medical inspection for the detection of 
contagious diseases may well be a fimction of the 
board of health. 

(b) Physical examinations for the detection of 
non-contagious defects should be conducted by the 
educational authorities, or at least with their full 
cooperation, because they are made for educational 
purposes. 

(c) The records of physical examinations must 
be constantly and intimately connected with school 
records and activities. 

(d) They do not need to be connected with other 
work of the board of health. 



CHAPTER XI 

Legal Aspects of Medical Inspection 

On Friday, April 17, 1908, Mr. Almuth C. Vandiver, counsel for 
the Medical Society of the County of New York, read a paper on " Statu- 
tory Enactments relating to the Medical and Sanitary Inspection of 
Schools" before the Second Congress of the American School Hygiene 
Association, then in session at Atlantic City. Most of the facts pre- 
sented in the following chapter have been through the courtesy of Mr. 
Vandiver taken from his paper. 

There are few legislative enactments under which the views and 
beliefs, and results of experience, of educators and physicians have been 
crystallized in Europe and America in the field of medical inspection of 
schools. There are but two important statutes. The English statute, 
which became a law on January i, 1908, and that of the State of 
Massachusetts. This commonwealth, always foremost in pioneer and 
progressive legislation, placed upon its statute books in 1906 a manda- 
tory medical inspection law far more comprehensive in its provisions 
than the English law. 

The English law, known legally as " Section 13 of the Administrative 
Provisions of the Education Act of 1907," in its entirety is as follows: 

13. (i) The powers and duties of a local education 
authority under Part III of the Education Act, 1902, 
shall include: (a) Power to provide for children attend- 
ing public elementary schools, vacation schools, vacation 
classes, play centers, etc. (b) The duty to provide for the 
medical inspection of children immediately before or at 
the time of or as soon as possible after their admission to a 
public elementary school, and on such other occasions 
as the Board of Education direct, and the power to make 
such arrangements as may be sanctioned by the Board of 

IS9 



l6o Medical Inspection of Schools 

Education for attending to the health and physical condi- 
tion of the children educated in public elementary schools: 
Provided, that in any exercise of powers under this section 
the local education authority may encourage and assist 
the establishment or continuance of voluntary agencies, 
and associate with itself representatives of voluntary 
associations for the purpose. 

(2) This section shall come into operation on the 
first day of January, nineteen hundred and eight. 

The English lawmakers are not quite so verbose and prolix in statute 
drafting as are their American contemporaries, and the interpretation 
and construction of this short act was comprehensively treated by the 
Board of Education in a memorandum issued on November 22, 1907, 
before the act became effective, for the guidance of the administrative 
officers charged with the execution of the statute. 

This course differs somewhat from the American system. In the 
United States the construction and interpretation of statutes is left 
finally to the courts. This procedure is a lengthy and involved practice. 
In view of the fact that the memorandum referred to has the practical 
effect of a parliamentary enactment in the execution of the law, it may 
be well to quote from it somewhat extensively. 

It will be observed that the burden of executing the provisions of 
the statute is specifically laid upon the education authorities. This is 
a distinct departure from the established course heretofore pursued 
in matters relating to the public health. 

In the view, however, of the London Board of Education the present 
act is not intended to supersede the powers which have long been 
exercised by sanitary authorities under various public health acts, 
but is meant to serve rather as an amplification and a natural develop- 
ment of previous legislation. 

In order that friction between the education and health authorities 
may be avoided, if possible, the Board of Education in this memorandum 
advises a thorough and friendly cooperation with such authorities in 
the administration of the law. 

The second most noticeable feature about the act is that it makes 
medical inspection compulsory. Theretofore medical inspection had 



Legal Aspects of Medical Inspection i6i 

been more or less in vogue in various localities under the supervision 
of the education authorities, sometimes in conjunction with the health 
authorities. The central authority for the execution of the law is the 
Board of Education. The board's instruments are the local education 
authorities. In country areas this authority is the county council. 
It is suggested in the memorandum that the county council confer 
with and cooperate with the co\mty medical ofl&cer. It is also suggested 
that the county medical officer have an assistant appointed by the county 
council, whose duty shall be the inspection provided for by the statute. 

In county boroughs the town council, which is at the same time 
both the local authority for public health, and also the local education 
authority, is counselled to instruct their medical officer of health to 
advise the education committee. Where no medical officer has been 
appointed, it is suggested that his appointment be made by the educa- 
tion authorities. Where there is already a school medical officer, it is 
suggested that his appointment remain undisturbed. 

Although there is no provision for school nurses in the act, the Board 
of Education advised that wherever practicable such nurses be employed. 

The Board decided that not less than three inspections during the 
school life of a child will be necessary to secure the results desired. 
In certain areas, the Board may from time to time require inspection at 
shorter intervals and of a more searching character. 

The inspection of the sanitation of school buildings, the prevention 
of the spread of contagious diseases, and the supervision of the personal 
and home life of the child are also suggested. 

Finally, it should be observed that there is in the act no section 
whatever providing that parents of school children, found diseased or 
defective after such inspection, shall provide proper medical attention 
at the hands of their own physician or of the hospital authorities. 

"Every authority which has so far undertaken medical inspection," 
says Dr. Hackworth Stuart, commenting upon the new law, "has ex- 
perienced great difficulty in overcoming parental indifference and 
neglect in very many defective cases. In some cases it is at present 
impossible to persuade the parents to act on the notification made after 
the visits of inspection. Legal proceedings against the parents for 
neglect would not prove a very helpful custom for general adoption." 

Dr. Stuart suggests that inspection would become more fruitful in 



1 62 Medical Inspection of Schools 

its results if the education authorities were empowered to secure treat- 
ment of cases where recommendations of the inspectors are repeatedly 
neglected and to recover the costs from the parents. 

In this view it is difficult to coincide so far as the United States are 
concerned. 

In this country a penal provision seems essential for the proper 
execution of any law imposing a duty upon the people or any part of 
them. 

Prior to the adoption of the EngUsh statute, the education authorities 
in various localities carried on a system of notification to parents of 
defects found to exist in their children by school medical inspectors. 
In these notifications, the parents were advised to secure medical atten- 
tion without delay, and explanations for the necessity of such action 
were included, but there was no legal authority existent to compel the 
parents to secure such medical attention if the same was neglected. 

It was found by the school authorities in Hanley that the segregation 
of defective pupils during school hours and during play-time had a more 
satisfactory effect upon the parents than any other method adopted. 

Let us now consider for a comparison with the English statute the 
only legislative enactment existing in the United States making medical 
inspection mandatory. As it was the initial legislative effort in America 
along this line it seems worth while to quote it in extenso. Legally it is 
known as Chapter 502 of the Acts of 1906, and became a law of the 
State of Massachusetts on the ist day of September, 1906. It provides: 

Section i. The school committee of every city and 
town in the Commonwealth shall appoint one or more 
school physicians, shall assign one to each public school 
within its city or town, and shall provide them with all 
proper facilities for the performance of their duties as 
prescribed in this act: provided, however, that in cities 
wherein the board of health is already maintaining or 
shall hereafter maintain substantially such medical in- 
spection as this act requires, the board of health shall 
appoint and assign the school physician. 

Section 2. Every school physician shall make a prompt 
examination and diagnosis of all children referred to him 



Legal Aspects of Medical Inspection 163 

as hereinafter provided, and such further examination of 
teachers, janitors, and school buildings as in his opinion 
the protection of the health of the pupils may require. 

Section 3. The school committee shall cause to be 
referred to a school physician for examination and diag- 
nosis every child returning to school w^ithout a certificate 
from the board of health after absence on account of illness 
or from unknown cause; and every child in the schools 
under its jurisdiction who shows signs of being in ill 
health or of suffering from infectious or contagious 
disease, unless he is at once excluded from school by the 
teacher; except that in the case of schools in remote 
and isolated situations the school committee may make 
such other arrangements as may best carry out the pur- 
poses of this act. 

Section 4. The school committee shall cause notice of 
the disease or defects, if any, from which any child is 
found to be suffering to be sent to his parent or guardian. 
Whenever a child shows symptoms of smallpox, scarlet 
fever, measles, chickenpox, tuberculosis, diphtheria or 
influenza, tonsillitis, whooping cough, mumps, scabies, or 
trachoma, he shall be sent home immediately, or as soon 
as safe and proper conveyance can be found, and the board 
of health shall at once be notified. 

Section 5. The school committee of every city and 
town shall cause every child in the public schools to be 
separately and carefully tested and examined at least 
once in every school year to ascertain whether he is suf- 
fering from defective sight or hearing or from any other 
disability or defect tending to prevent his receiving the 
full benefit of his school work, or requiring a modifica- 
tion of the school work in order to prevent injury to the 
child or to secure the best educational results. The tests 
of sight and hearing shall be made by teachers. The 
committee shall cause notice of any defect or disability 
requiring treatment to be sent to the parent or guardian 
of the child, and shall require a physical record of each 



164 Medical Inspection of Schools 

child to be kept in such form as the state board of educa- 
tion shall prescribe. 

Section 6. The state board of health shall prescribe 
the directions for tests of sight and hearing and the state 
board of education shall, after consultation with the 
state board of health, prescribe and furnish to school 
committees suitable rules of instruction, test cards, 
blanks, record books, and other useful appliances for 
carrying out the purposes of this act, and shall provide 
for pupils in the normal schools instruction and practice in 
the best methods of testing the sight and hearing of 
children. The state board of education may expend diir- 
ing the year nineteen hundred and six a sum not greater 
than fifteen hundred dollars, and annually thereafter a 
sum not greater than five hundred dollars for the pur- 
pose of supplying the material required by this act. 

Section 7. The expense which a city or town may incur 
by virtue of the authority herein vested in the school com- 
mittee or board of health, as the case may be, shall not ex- 
ceed the amount appropriated for that'purpose in cities by 
the city council and in towns by a town meeting. The 
appropriation shall precede any expenditure or any in- 
debtedness which may be incurred under this act, and the 
sum appropriated shall be deemed a sufficient appropria- 
tion in the municipality where it is made. Such appropria- 
tion need not specify to what section of the act it shall apply, 
and may be voted as a total appropriation to be applied in 
carrying out the purposes of the act. (Repealed in 1908.) 

Section 8. This act shall take effect on the first day of 
September in the year nineteen hundred and six. (Ap- 
proved June 20, 1906.) 

It will be noted that the provisions of section 7 enabled any city coun- 
cil or town meeting to render ineffective the whole medical inspection 
law, by refusing to grant a proper appropriation therefor. A few cities 
and towns availed themselves of this opportunity, and in order to avoid 
this possibiUty the legislature of 1908 repealed the section. 



Legal Aspects of Medical Inspection 165 

Observe that the English statute and the Massachusetts statute each 
make medical inspection compulsory. 

Neither includes a penal provision providing for procedure against 
neglectful parents of defective children. 

In these two essentials, the acts are similar. 

In the English act, the education authorities are charged with the 
administration of the law. In Massachusetts, the school authorities in 
every city or town appoint medical examiners, except in cities where the 
board of health is already maintaining or shall hereafter maintain such 
medical inspection as the act requires. In this latter class the board of 
health appoints. 

In the Massachusetts statute, an examination of each pupil is pro- 
vided at least once in every school year for defective sight or hearing, or 
any other disability. The tests are given by the teachers, but the board 
of health prescribes the directions for tests. Notices of defects must be 
sent to the parents. 

In the English statute, there is no expressed provision for the number 
of medical examinations, but as has hereinbefore been stated, the London 
Board of Education has prescribed three examinations during a school 
life as necessary. 

These are the leading statutes in Europe and America upon this sub- 
ject. The American statute has been in effect for less than two years, the 
English statute a little over one-half year. Neither, therefore, can be 
considered as yet away from the experimental stage of legislation. 

Let us now consider the work of medical inspection done without 
specific mandatory legislative enactment, and done under the existing 
permissive provisions of the Public Health Laws of the State of New 
York, in the most populous city of America. 

New York state has no specific statute making medical inspection 
compulsory. Such inspection is conducted in the city of New York by 
the Department of Health under the general authority of the PubHc 
Health Laws, authorizing local health boards to guard against the intro- 
duction of contagious and infectious diseases by the exercise of proper and 
vigilant medical inspection, and the control of all persons and things 
arriving in the municipality from infected places, or which from any cause 
are liable to communicate contagion. This statute is Section 24 of Arti- 
cle 2 of Chapter 661 of the Laws of 1893 and amendments thereto. 



1 66 Medical Inspection of Schools 

Section 210 of Article 12 of the same statute makes the vaccination of 
school children compulsory. 

To show the attitude of the people of New York, it may be said that 
the enforcement of this section was bitterly contested to the Court of Final 
Appeal, where its constitutionality was affirmed in October, 1901. 

Although no legislative enactment yet appears upon the statute books 
of New York in regard to compulsory medical inspection of school chil- 
dren, more consideration has been displayed in section 213 of Article 12 of 
the same law, in regard to the examination and quarantine of children 
admitted to institutions for orphans, destitute or vagrant children, or 
juvenile delinquents. 

This section provides : 

"Every institution in this state, incorporated for the 
express purpose of receiving or caring for orphan, vagrant 
or destitute children or juvenile delinquents, except hos- 
pitals, shall have attached thereto a regular physician of 
its selection duly licensed under the laws of the state and 
in good professional standing, whose name and address 
shall be kept posted conspicuously within such institution 
near its main entrance. The words 'juvenile delin- 
quents' here used shall include all children whose com- 
mitment to an institution is authorized by the penal code. 
The officers of every such institution upon receiving a child 
therein, by commitment or otherwise, shall, before ad- 
mitting it to contact with the other inmates, cause it to be 
examined by such physician, and a written certificate to be 
given by him, stating whether the child has diphtheria, 
scarlet fever, measles, whooping cough or any other con- 
tagious or infectious disease, especially of the eyes and skin, 
which might be commimicated to other inmates and speci- 
fying the physical and mental condition of the child, the 
presence of any indication of hereditary or other consti- 
tutional disease, and any deformity or abnormal condition 
found upon the examination to exist. No child shall be so 
admitted until such certificate shall have been furnished, 
which shall be filed with the commitment or other papers 



Legal Aspects of Medical Inspection 167 

on record in the case, by the officers of the institution, who 
shall, on receiving such child, place it in strict quarantine 
thereafter from the other inmates, vintil discharged from 
such quarantine by such physician, who shall thereupon 
indorse upon the certificate the length of quarantine and 
the date of discharge therefrom." 

" Section 214. Monthly examination of inmates and 
reports. — Such physician shall at least once a month 
thoroughly examine and inspect the entire institution, and 
report in writing, in such form as may be approved by the 
state department of health, to the board of managers or 
directors of the institution, and to the local board of the 
district or place where the institution is situated, its condi- 
dition, especially as to its plumbing, sinks, water-closets, 
urinals, privies, dormitories, the physical condition of the 
children, the existence of any contagious or infectious 
disease, particularly of the eyes or skin, their food, clothing 
and cleanliness, and whether the officers of the institution 
have provided proper and sufficient nurses, orderlies, and 
other attendants of proper capacity to attend to such chil- 
dren, to secure to them due and proper care and attention 
as to their personal cleanliness and health, with such 
reconomendations for the improvement thereof as he may 
deem proper. Such boards of health shall immediately 
investigate any complaint against the management of the 
institution or of the existence of anything therein danger- 
ous to life or health, and, if proven to be well founded shall 
cause the evil to be remedied without delay." 

The penal provisions of the Health Law in regard to violations 
thereof provide : 

"Section 397. Wilful violation of Health Laws. — i. A 
person who wilfully violates or refuses or omits to comply 
with any lawful order or regulation prescribed by any 
local board of health or local health officer, is guilty of a 
misdemeanor. 

*' 2. A person who wilfully violates any provision of the 



1 68 Medical Inspection of Schools 

health laws, or any regulation lawfully made or established 
by any public ofi&cer or board under authority of the health 
laws the punishment for violating which is not otherwise 
prescribed by those laws, or by this code, is punishable by 
imprisonment not exceeding one year, or by a fine not 
exceeding two thousand dollars or by both." 

The Public Health Laws of the State of New York are sufl&ciently 
broad and comprehensive in their general authorizing provisions to 
warrant the establishment and maintenance by the health authorities 
of an adequate system of medical inspection of school children. Hearty 
cooperation on the part of the education authorities is essential, how- 
ever, to make the work effective. 

In 1892, medical inspection in the parochial schools of Philadelphia 
was established and was soon discontinued on accoimt of much opposi- 
tion thereto. 

In 1890, Boston ordered such medical inspection, but did not enforce 
it until 1894. 

In 1895, Chicago followed suit. 

The principle upon which medical inspection of schools was estab- 
lished in these cities, and in fact the principle upon which medical 
inspection has proceeded in all of the states in the Union, has been the 
prevention and elimination of infectious and contagious diseases, and 
not upon the high intellectual plane upon which the Board of Educa- 
tion of London in the memorandum before referred to have placed the 
reasons for the enactment of their legislation in the following words : 

" The Board desires, therefore, at the outset to emphasize 
that this new legislation aims not merely at a physical or 
anthropometric survey, or at a record of defects disclosed 
by medical inspection, but at the physical improvement, 
and, as a natural corollary, the mental and moral improve- 
ment, of coming generations. The broad requirements of 
a healthy life are comparatively few and elementary, but 
they are essential, and should not be regarded as applicable 
only to the case of the rich. In point of fact, if rightly 
administered, the new enactment is economical in the best 
sense of the word. Its justification is not to be measured 



Legal Aspects of Medical Inspection 169 

in terms of money, but in the decrease of sickness and 
incapacity among children, and in the ultimate decrease of 
inefficiency and poverty in after life arising from physical 
disabilities." 

In 1897, ^5° physicians were appointed by the Department of Health 
of New York to inspect schools. 

In 1907, there were 166, together with 50 trained nurses, at work. 

From 1897 to 1902, the efforts of these physicians were directed to 
excluding children with infectious and contagious diseases. 

In 1902, each child was personally examined once a week. 

In 1905, the examination of each child thoroughly to ascertain the 
existence of any contagious affection was instituted. 

No child was treated whose parents were able to employ physicians. 

The fundamental principles in force at that time were: 

1. Repeated and systematic inspection of all school children for the 
purpose of early recognition of contagious diseases. 

2. Exclusion from school attendance of all children affected with an 
acute contagious disease. 

3. Subsequent control of case with isolation of patient and disinfec- 
tion of the living apartment after termination of illness. 

4. Control and enforced treatment of minor contagious ailments 
with the purpose of diminishing the number of children excluded from 
school attendance. 

5. Knowledge of unreported cases of contagious diseases. 

6. Complete physical examination of each school child with reference 
to the existence of any physical or mental abnormality. 

The working officers consisted of a chief medical inspector, a corps 
of physician inspectors, a supervising nurse, and a corps of trained 
nurses. 

In the English statute there is no provision for the employment of 
school nvu*ses, but such employment is recommended wherever feasible. 

It seems to be the general opinion of hygienic experts that admirable 
results in the furtherance of medical inspection, especially in the home 
treatment of defective children, have been obtained by the employment 
of school nurses. 

Under the regulations of the New York Health Department, each 



1 70 Medical Inspection of Schools 

physician inspector visited a group of schools before ten in the morning 
and examined: 

1. All children isolated by the teachers suspected of contagious 
diseases. 

2. All children who had been absent from school for any reason. 

3. All affected children neglecting treatment. 

4. All cases referred by the school nurse for diagnosis. 

Upon diagnosis of contagious disease, the child was sent home and 
could not return to the school except on the certificate of the Depart- 
ment of Health as to the termination of the disease. 

Children suffering from skin diseases were ordered to go to their 
family physician, or to dispensaries, or to the school nurse for treatment. 

The nurses were assigned to schools in crowded tenement districts, 
and treated such pupils as were sent to them by the medical inspectors. 

Routine weekly inspections were also made by the nurse. 

All doubtful cases were referred for diagnosis. 

In 1905, the nurses treated 976,092 cases. 

Two dispensaries and one hospital for trachoma were established. 

Absentees were visited by the physicians and by the nurses. 

The Superintendent of Schools of New York in his annual report 
for 1907, has recommended legislation establishing a Department of 
Hygiene, to be placed under the sole and exclusive jurisdiction of the 
education authorities as the most important and necessary work to be 
accomplished at the present time by the Board of Education. 

Here is food for expert thought. 

Specific, compulsory legislation authorizing the education authori- 
ties in the city of New York to conduct medical inspection is suggested 
by the chief executive officer of the city schools, in the greatest city 
in the country. Dual responsibility is deprecated. 

On the side of the sole jmrisdiction of the education authorities 
stands the English statute. 

The tendency of the Massachusetts statute is to put the jurisdiction 
in the education authorities. In the latter, however, there is co- 
ordinate reference to the health authorities. 

It will be interesting to observe the measure presented for enactment 
in the state of New York, after due and proper discussion on the subject 
from all points of view. 



Legal Aspects of Medical Inspection 171 

None of the other states of the Union have specific statutes making 
medical inspection mandatory. 

New Jersey has a statute making medical inspection permissible. 
This statute went into effect on October 19, 1903. It is Section 229 
of Article 27 of the School Laws, and is as follows: 

"Medical Inspector. Duties. — 229. Every Board of 
Education may employ a competent physician to be 
known as the medical inspector, fix his salary and define 
his duties. Said medical inspector shall visit the schools 
in the district in which he shall be employed at stated 
times to be determined by the board of education, and 
diuring such visits shall examine every pupil referred to 
him by a teacher. He shall at least once during each 
school year examine every pupil to learn whether any 
physical defect exists, and keep a record from year to year 
of the growth and development of such pupil, which record 
shall be the property of the board of education and shall 
be delivered by said medical inspector to his successor in 
ofiice. Said inspector shall lecture before the teachers at 
such times as may be designated by the board of education, 
instructing them concerning the methods employed to 
detect the first signs of communicable disease and the 
recognized measures for the promotion of health and pre- 
vention of disease. The board of education may appoint 
more than one medical inspector." 

Vaccination is compulsory under the same statute, as it is in most 
states. 

The superintendent of the city schools of Newark is authority 
for the statement that there has been medical inspection in Newark 
for seven years last past. 

The weak point in the New Jersey law, in his opinion, consists in 
the lack of authority vested in the Board of Health or in the Board of 
Education to compel parents to give suitable treatment to those children 
excluded from school because of physical defects needing surgical treat- 
ment, etc. 



172 Medical Inspection of Schools 

He also says : 

" It is the purpose of the Board of Education of this city 
to take over the full control of medical inspection of pupils 
combined with the approval of the Board of Health, 
which until now has shared responsibility. There are 
several important reasons with us why it is desirable that 
the Board of Education should have the sole responsibility 
in the matter of medical inspection and treatment of 
school pupils." 

In Newark medical inspectors are by Section II of the Board of 
Education instructions at all times under the immediate direction and 
control of the Board of Health in all matters pertaining to the per- 
formance of their duties. They are required to make a daily report to 
the Board of Health. 

The matter of more thorough inspection is now under consideration 
in New Jersey. 

In the belief that the legal status of medical inspection in the more 
progressive states of the Union, and the lack of the same in other states, 
might be interesting and perhaps helpful, an attempt has been made to 
collate the information relating thereto furnished by the health and 
education authorities of the various state governments. 

In Maryland there is no statutory requirement for individual inspec- 
tion and medical treatment of school children. In Baltimore there is 
medical inspection under the city ordinances. 

Section 5 of Article 43 of the Code of Public Health Laws of Mary- 
land provides, in reference to the duties of the Secretary of the State 
Board of Health, that "He shall when requested by local boards visit 
their respective districts, cities or villages, investigate the cause of any 
existing disease, and shall from time to time and whenever directed by 
the Governor or legislature make special inspections of public hospitals, 

asylums, prisons and other institutions, and shall when 

required by the Governor or other proper authorities advise in regard 

to the location, drainage, water supply and ventilation 

of any public institution " 

Section 22, same article, provides that "the board of County Com- 
missioners in the several coimties in this State shall ex officio constitute a 



Legal Aspects of Medical Inspection 173 

local board of health for their respective counties and shall have and 
exercise all the duties of a board of health as provided in this article. 



The general authority to make such inspections under the Public 
Health Laws is given to the state and local boards of health. 

The secretary of the State Board of Health does not believe it ex- 
pedient to provide special legislation for the purpose of sanitary inspec- 
tion of schools if the general statutes give the necessary power. 

He is also of the opinion that individual attention to the health of 
school children is best provided for by local ordinances or regulations. 

In Pennsylvania there is no legislation relative to medical and sani- 
tary inspection of public schools. 

In the rural districts the State Department of Health has considered 
that, in its duty to protect the health of the public generally, it should 
make sanitary inspections, inasmuch as this matter appeared to be 
entirely neglected. In Philadelphia the local Board of Education has 
taken up the matter with the assistance of the local Board of Health. 

In Philadelphia school nursing has also received some attention, 
but so far as the action of the State Legislature is concerned, nothing 
has been done. 

The view of the Assistant Commissioner of Health in Pennsylvania 
is that sanitary inspection, referring to construction, location, etc., 
is a proper function of the Board of Education, and that the medical 
inspection, which involves the examination of pupils by physicians, 
should be undertaken by the Board of Health. 

The chief of the Bureau of Health of the city of Philadelphia says 
that the work in Philadelphia was the outcome of an agreement between 
the Bureau of Health and the Board of Education, and approved by 
City Councils, who furnished the means for the conduct of the work. 

In so far as the treatment of children found in the schools suffering 
from disease is concerned, the great majority of them are looked after 
by their parents. Those who cannot be looked after by their parents, 
are attended by the district physician or by some one or another of the 
hospitals in the city. 

Children having defective vision, who are in such destitute circum- 
stances that their parents cannot provide necessary relief, are relieved 
by this Bureau at the city's expense. 



174 Medical Inspection of Schools 

The Bureau has an expert ophthalmologist making examinations, 
and money is provided for the piirchase of glasses. 

The chief is an advocate of school inspection. He believes it is 
only partially successful. 

He thinks it is imsatisfactory, that continuously, in the schools of 
their city, children are foimd who should be imder the care of specialists ; 
some of them requiring orthopedic corrections, some of them mentally 
enfeebled, and some epileptic, and others suffering from similar afflic- 
tions. These cases cannot be properly looked after by the means at the 
Biureau's disposal. He suggests special schools for children who are 
abnormal in any particular. 

The Bureau has no difficulty with children who are acutely sick. 
If their parents pay no attention to their condition, it is within the power 
of the Bureau to convey them to one or another of the hospitals under 
the Bureau's control. 

In Illinois there is no specific legislation relative to sanitary and 
medical inspection of public schools. 

The local boards of health throughout the state are legally em- 
powered to inaugurate and carry on such inspections. There is no law 
legalizing inspection of pupils in schools. Chicago has city ordinances 
under which sanitary inspection of school buildings is carried out. Also 
medical inspection of school pupils for the purpose of keeping out 
infectious diseases. There is no examination for physical or mental 
defects at present. The law does not authorize such. The medical 
inspector of the Department of Health, however, states that the Depart- 
ment of Health expects to try making such examinations and to endeavor 
to show results which wiU justify making laws legalizing such work. 

In the District of Columbia there is medical inspection imder rules 
formulated by the health officer in 1903, and approved by the Board of 
Education, in accordance with an act making appropriations to provide 
for the expenses of the government of the District of Coliunbia. They 
were amended in 1907. 

These rules have the full legal force and effect of law. 

In regard to inspection, the health officer says : 

" School nursing has not yet been provided in this Dis- 
trict, but the Commissioners have recommended that an 



Legal Aspects of Medical Inspection 175 

appropriation be made for the services of two nvirses to 
operate in connection with the medical inspectors of 
schools. The only present means of enforcing the parental 
obligation to provide treatment for school children after 
exclusion from school is through the truancy act. If a 
child is excluded and a parent does not adopt such meas- 
ures as may be necessary to permit it to return to school, it 
might, if the measures to be adopted are reasonable and 
within the reach of the parent, be possible to compel action 
by the parent by prosecution for failing to send the child 
to school. This procedure has, however, not yet been 
tried in court, although the possibility of it has been a 
weapon effectually used in certain cases. 

" In my judgment, it is quite as important for the state 
to look after the physical welfare of its children as it is for 
it to provide for their mental training, and I feel that justi- 
fication could be found in the laws of most jurisdictions 
for every proper means toward that end; not necessarily 
existing statutes or regulations, but, if not, then warrant 
in the constitution, federal and state, for the enactment of 
such statutes and the promulgation of such regulations. 
The supreme authority which the state may exercise with 
respect to the physical welfare of pupils in attendance on 
public schools is shown, I beUeve, by the general trend 
of decisions in cases in which vaccination has been required 
as a condition precedent to school attendance." 

The regulations governing the medical inspection of pubHc schools in 
the District of Columbia provide for an examination by the teacher, and 
if any indications of defects or disease are discovered by her lay mind, 
the medical inspector must be summoned. 

The medical inspector is required also to make perfunctory routine 
visits to the schools. 

No physical examination of the pupils of any entire room or building 
is to be imdertaken except so far as may be necessary for the detection 
of communicative diseases and defects of sight and hearing, without the 
consent of the Board of Education. 



176 Medical Inspection of Schools 

California. — There is but one law on the statute books of this State 
for medical attention to be bestowed upon public schools children. 

Many years ago a special act providing that no Board of School 
Trustees or Boards of Education shall permit any child to attend the 
public school who fails to show satisfactory evidence of vaccination, 
was enacted. The law met with much opposition. At each session of 
the Legislature its repeal is attempted. At Berkeley (site of State Uni- 
versity) the an ti- vaccinationists operate a school for their own children 
at their own expense. 

This information is from R. H. Webster, Deputy Superintendent of 
the Schools of San Francisco. 

Mr. Webster thinks there should be systematized medical inspection 
of children attending the public schools, and further that necessary 
treatment be provided in case that the parent or guardian of a child is 
in indigent circumstances. 

The matter is being considered in some cities, notably Los Angeles. 

A bill will be introduced into the next Legislature. 

Colorado. — There are no laws relative to medical and sanitary 
inspection of schools by boards of health. 

General statutes creating the state and local boards of health give 
necessary power. 

The local health officers of the various towns and coimties maintain 
supervision over the schools in their districts for the prevention of con- 
tagious and infectious diseases. 

The Health Department at Denver arranges for an examination of 
the pupils in the various schools at stated times. 

The Health Board of the state has insufficient fimds to go into the 
work as thoroughly as they should. 

Connecticut. — ^The Legislature of Connecticut, in 1899, passed a 
law providing for the testing of eyesight in all the public schools of the 
state. Under the law, the State Board of Education is required to 
fiu-nish test cards and blanks and instructions for their use to the school 
authorities. The superintendent, principal, or teacher in every school 
is required to test the eyesight of all the pupils during the fall term and 
notify in writing the parent or guardian of every pupU who has any 
defect of vision, with a brief statement of each defect. The tests are 
made triennially. The boards of education and school committees 



Legal Aspects of Medical Inspection 177 

in the several towns of the state, under the authority granted in the 
general statutes, may appoint physicians to act as school inspectors. 

Florida. — There are no statutes looking to the protection of school 
children either in the construction of school houses or in the examina- 
tion of the pupils. 

In 1907, an effort was made by the State Board of Health to obtain 
some general legislation in regard to health and sanitary matters, but, 
in the language of the secretary, who is the State Health Officer: "A 
difficulty exists always in trying to acquire legislation of this kind which 
has no political significance or interest to the politicians, and the failure 
of the State Board of Health to better the sanitary and health condition 
of the people in this direction through legislative enactment was due 
altogether to these causes, and not to any interest or efforts on the part 
of the Board to effect the same." 

Georgia. — No legislation. The secretary of the Health Board says : 

"The matter of public hygiene has been given practic- 
ally no consideration in this part of the country as yet, 
though I trust that in the future it will receive more atten- 
tion. There is no question of the fact that there is great 
need of such legislation, but I see very little hope of any- 
thing being done in that line in the near future in this 
state." 

Idaho. — The State Board of Health was organized in 1907. There 
is a local board of health in each cotmty, consisting of the county physi- 
cian and the county commissioners. The State Board requires the 
inspection of public school houses as to their sanitary condition twice a 
year. 

There is no law covering the inspection of school children. 

Indiana. — The secretary of the State Board of Health tells Indiana's 
story in the following words : 

"Your letter received asking information concerning 
Indiana's Statutes which refer to the medical inspection of 
school children. There is not a single statute relative to 
this subject in Indiana. We simply let our defective and 



178 Medical Inspection of Schools 

sick children die, and all pleas heretofore made to our 
legislatvire have been rejected. We hope some day that 
Indiana will rise above this barbarism by the people send- 
ing men to the legislature who are intelligent and pro- 
gressive enough to take hold of this great and important 
subject. 

" We are sorry that Indiana cannot make a better report. 
Indianapolis, at one time, had medical school inspection, 
but just now, there is a quarrel between the City Council 
and the school board, as to who shall pay the bill, and 
nothing is being done. Between looking after the health 
of our children and having the pleasure of a quarrel among 
politicians, we know which way it will go." 

Indiana boards of health, however, may make medical inspection 
of schools under the general statutes. 

Kansas. — No legislation requiring medical and sanitary inspection 
of schools by boards of education. 

In igo6, the State Board of Health made a rule requiring a critical 
sanitary inspection by county health officers of every public school 
building in their jiurisdiction, and during the summer vacation requiring 
that each school house be thoroughly and efficiently fumigated before 
the fall term of school began. This rule has been quite generally and 
effectively put into execution during the past two years, and many 
unsanitary and unwholesome conditions found and rectified. 

The Board of Health considers that there is much need for special 
legislation along these lines. 

In 1907 a bill providing for medical inspection was defeated. 

Kentucky. — No provision has been made by the state or city for 
medical and sanitary inspection of public schools. 

At the last meeting of the Legislature a bill was introduced providing 
for medical inspection in cities of the first, second and third classes. 
This biU failed of passage in the rush of business at the end of the session. 

Michigan. — No specific laws relating to the medical and sanitary 
inspection of schools. No obligation upon the parents or mimicipality 
to provide treatment when a child having some contagious disease that 
is dangerous to public health has been excluded from school. 



Legal Aspects of Medical Inspection 179 

Detroit and one or two other cities have inaugurated medical inspec- 
tion of schools, and the results are most satisfactory. 

The secretary of the Board of Health believes that there should be 
not only medical inspection of the pupils, but a general supervision of 
buildings and grounds, toilets, heating, ventilating, and all the conditions 
under which a child is obliged to acquire an education. 

A general revision of the health laws at the next session of the Legis- 
latiure is being advocated. 

The schools of Detroit are inspected daily by physicians appointed 
by the Board of Health. There are 27 inspectors, each receiving a 
salary of $250 per year. The physicians do not prescribe. 

Minnesota. — The State Board of Health advises that medical inspec- 
tion is to be made throughout the state wherever possible, but under the 
present laws school inspection cannot be insisted upon. 

For some years, the Health Board has tried to secure the examination 
of the eyes and ears of school children throughout the state. In the 
smaller places, the Board has met with liberal support, but the larger 
cities, Minneapolis and St. Paul, have not yet fallen into line in this work. 
Minneapolis, during the winter of 1907 and 1908, has endeavored to 
introduce school inspection. 

Medical inspection, except in an experimental way, has not been 
carried on. There is no legislation, except that cities are permitted to 
introduce medical inspection if they see fit. 

The Health Commissioner is in sympathy with medical inspection 
carried on primarily as an aid to departments of health in the early 
detection of all kinds of contagious diseases. He thinks that if this 
should be pursued to the extent of employment of school nurses, it would 
prove pernicious. 

Nebraska. — No special laws. 

"Nebraska," says the health inspector of the state, "being yoimg 
and but lightly populated, and having abundance of pure air, does not, 
perhaps, stand so much in need of such laws as you of the east, with 
your dense population overcrowded cities, and smoky and noxious 
atmosphere." 

New Hampshire. — No legislation requiring medical inspection or 
providing treatment after inspection. 

No legalized system of sanitary inspection. 



i8o Medical Inspection of Schools 

Sanitary inspections of school buildings are occasionally made by 
local boards of health, more particularly upon complaint of parents, 
teachers, or school boards. 

The views of the secretary of the State Board of Health are that 
medical inspection of school children ought to be made everywhere, 
and that legal responsibility for the treatment of such as require it should 
be placed upon parents, if able, and otherwise, on the municipality. 

Ohio. — The present statutes permit boards of health to establish 
systems of medical inspection for the prevention of communicable 
diseases, and also permit such boards to make an inspection of school 
buildings twice a year for the purpose of determining conditions of 
lighting, ventilation, etc. There is nothing mandatory in this legislation 
and it is not likely that anything concerning this matter will be enacted 
during the present session of the Legislature, 

The feeling of the Board of Education is that boards of education 
should be empowered to make medical examinations of all school children 
and that there should be power conferred enabling the Board to require 
parents to do whatever is foimd necessary following such examinations. 
At the present time, the Board invokes the Juvenile Court in all matters 
coming to oiur attention. They are enabled on the charge of "neglect 
of children" to bring most parents to time in these matters. 

Oklahoma. — No laws at present. The first State Legislature now 
in session. 

Oregon. — No legislation in regard to medical and sanitary inspection 
of schools, other than that given city, county, and state boards of 
health in the state health laws. The State Board of Health has been in 
existence but five years. 

In the city of Portland there is a system of medical inspection, 
the inspection being given by various doctors throughout the city 
gratuitously. 

No legalized system or school nursing. 

The state health officer believes that every school should have 
thoroughly competent and well paid physicians to make regular examina- 
tions of all school children, as well as to give instructions to teachers 
relative to school sanitation, school hygiene, and the general health of 
the children. He also believes that this system should be carried into 
the country school districts. 



Legal Aspects of Medical Inspection i8i 

Rhode Island. — No legislation. Some inspection in Providence and 
Newport. 

Texas. — Sanitation of school buildings is required. No other laws. 

Local school boards have been interested in eye inspection, and 
specialists have been persuaded to make these examinations without 
charge. The same has been done with the ear, nose, and throat 
troubles. 

Texas is behind in these matters, but shows willingness to catch up. 

Utah. — Legislation expected at the next session of the Legislature. 

The State Board of Health has provided for the testing of the eyes 
of school children, and also examination as to the presence of defective 
hearing and of mouth breathing, the said test to be made by the teacher, 
and upon the discovery of any of the defects described, reporting the 
fact to the parents with recommendation that the child shall be examined 
by a competent specialist. 

The State Board of Health is also preparing rules making it the duty 
of teachers to report unsanitary or unhygienic conditions in the schools, 
including improper construction, and to use vigilance in the detection of 
symptoms of contagious disease among the pupils and the immediate 
exclusion of any pupil suspected of being so affected. 

The secretary thinks it should be the duty of all parents to provide 
for a competent physical examination of children before permitting 
them to enter school, the said examination to determine the presence of 
any defect requiring correction. He also thinks that the state should 
insist that the correction should be furnished by the parent. 

The last Legislature passed a law requiring the introduction in the 
public schools and in the normal schools of a course of instruction on 
the subject of preventable disease and preventive methods. 

Vermont. — No special legislation, except requirements as to ven- 
tilation, light, and general sanitary conditions in school buildings. 
Also a law requiring the examination of the eyes, ears, and throats of 
school children annually, enacted in 1904. 

The secretary of the State Board of Health says that it is very 
difficult to formulate a law in a rural state like Vermont, where, outside 
of a few large towns, the schools are small and widely scattered. 

South Carolina. — No legislation, aside from general statutes. 

The State Board of Inspectors, the public schools, and the State 



iSz Medical Inspection of Schools 

Board of Health are now inaugurating a system to protect the eyes and 
ears of school children. 

Washington. — No general laws. 

In the larger cities the matter is more or less covered by city ordin- 
ances and board of health regulations. 

Wisconsin. — Very little definite legislation regarding school inspec- 
tion. 

The State Board of Health is empowered under the general law 
to make observations and enforce proper sanitary care of school 
houses. 

The State Board of Health has endeavored through inspectors to 
see that the school houses were properly heated, ventilated, and lighted. 

No provision has been made for treatment of school children after 
such inspection. 

No legalized system of school musing or legislation on subjects 
kindred thereto. 

The Board is endeavoring to formulate methods in regard to the 
testing of eyes, ears, nose, and throat of school children. 

This question will probably be considered at the 1909 session of the 
State Legislature. 

In the following states there are no laws, aside from the general 
statutes, upon the subjects referred to: 

Louisiana Montana 

Maine Nevada 

Mississippi North Dakota 

Missouri South Dakota 

In the following states inquiries regarding medical inspection were 
unanswered : 

Alabama North Carolina 

Arizona Tennessee 

Arkansas Virginia 

Delaware West Virginia 

Iowa Wyoming 
New Mexico 



Legal Aspects of Medical Inspection 183 

From the legal domain the suggestions prompted by the foregoing 
study are the following: 

Those having a part in the future of medical inspection should exert 
themselves to the utmost to secure so far as possible vmiformity in 
statutory provision. 

Legislation should provide that medical inspection shall be com- 
pulsory. 

That local conditions determine whether the onus of executing the 
law be upon the health or the education authorities. 

Insert a penal provision compelling parents or guardians to provide 
proper medical attention upon the order of the medical examiner. 

Most essential of all — insure the law's enforcement. 



CHAPTER XII 

Retardation and Physical Defects 

EDUCATIONAL ECONOMIES EFFECTED THROUGH 
MEDICAL SUPERVISION 

The memorandum of the British Board of Education on "Medical 
Inspection of Children in Public Elementary Schools," states in a few- 
brief words the fundamental basis upon which medical inspection rests. 
Of the recent English law it says : 

"It (the law of 1908) is founded on a recognition of the 
close connection which exists between the physical and 
mental condition of the children and the whole process of 
education. It recognizes the importance of a satisfactory 
environment, physical and educational, and by bringing 
into greater prominence the effect of environment upon the 
personality of the individual child, seeks to secure ulti- 
mately for every child, normal or defective, conditions of 
life compatible with that full and effective development of 
its organic functions, its special senses, and its mental 
powers, which constitute a true education." 

That there must exist a close relation between mental and physical 
conditions no one will deny, but how important the relation is when 
measured in terms of its effect on the educational progress of school 
children, and whether indeed such measurement in quantitative terms 
is possible, are problems which have been seldom studied, and if at all, 
in the most casual fashion. 

With some notable exceptions, those who have occupied themselves 
with these matters have assumed that there exists a correlation between 
school progress and physical defects so marked and so direct that could 
we but correct and prevent bodily unsovmdness among the pupils of our 



Retardation and Physical Defects 185 

schools, we should thereby at once do away with "backwardness" and 
"retardation." 

As a corollary to this hoped for disappearance of retardation not a 
few school men have argued that great financial economies would be 
effected and such evils as crowded rooms and "half time" schools 
rendered unnecessary. In some places this view has led to earnest 
argument in favor of the estabhshment of systems of medical inspection, 
and the plea has been made that the expense involved would be more 
than made up by the direct financial saving effected. An example is 
found in the latest annual report of the city superintendent of schools of 
one of the large New England cities. He pleads his case as follows: 

"Many children lose promotion and are compelled to 
repeat their work. Now, it costs the city in round num- 
bers $230,000 to educate its public school children. The 
average attendance is in the neighborhood of 93 per cent. — 
a loss of 7 per cent, on account of absence. Seven per 
cent, of $230,000, or more than $16,000, represents the 
annual waste caused by absence of children from school. 
If by a system of medical inspection this per cent, of 
attendance can be lifted only i per cent., it would amount 
to a saving of $1,600, or all that it would cost to secure 
good inspection for a city like ours." 

In other words, the superintendent argues that if every day 94 
children can be induced to attend school where now only 93 are present, 
a financial saving will result amounting to some $1,600. The fallacy 
of this argument is, of course, evident; but it is nevertheless one which 
has found enthusiastic support in many places and which has been widely 
used by the advocates of medical inspection. 

The contention that a successful system of medical inspection would 
go far toward eliminating the evil of " half time," because it would reduce 
the amount of retardation or backwardness in our school systems, rests 
on an equally mistaken basis. Nevertheless, this argument, too, has 
been eloquently stated and actively urged in many quarters. A district 
superintendent of one of our largest cities, an eminent and able educator, 
stated the argument but a few months ago in a discussion of retardation 
in different cities. He says: 



i86 Medical Inspection of Schools 

" Boston is now able to make the proud boast that she 
has a seat in school for every child able to attend. This 
condition may in part be due to the smaller percentage of 
retardation. Were the stream of children through the 
grades less rapid, perhaps she would have thousands and 
tens of thousands upon ' part time,' while empty benches 
yawn for occupancy in the highest grades. Damming the 
stream of children passing through the grades of our 
schools defeats the purpose of oiu: public educational sys- 
tem and causes a wasteful expenditure of public funds." 

And again: 

" The child that takes ten years to complete an eight year 
coiurse costs the state 25 per cent, more than the one that 
goes through on time." 

Here again the problem of retardation is brought into relation to the 
problems of accommodation and cost. Inasmuch as a principal argu- 
ment of the advocates of medical inspection is that physical defects con- 
stitute a potent force for causing retardation, these claims are of the 
greatest interest in the present discussion. The first contention in the 
above quotation is that if the progress of the children through the grades 
in the city referred to were less rapid than it is, there would as a conse- 
quence be thousands or tens of thousands of pupils upon "part time." 
At first sight this seems a perfectly sound contention; but the fact of the 
matter is that the children who do not progress through the school grades 
at the normal rate, and hence find themselves at the age of say foiurteen 
in the fifth or sixth grade instead of the eighth, do not as a rule continue 
two or three more years in order to finish, but instead drop out without 
completing the comrse. That is to say, a city must have enough seats 
to accommodate all of its children between the ages of say seven and 
fourteen years. It makes little difference in this particular problem what 
progress the children make: the necessity for accommodation remains 
the same, whether all of them complete the eight grades, or only a small 
percentage do so. Under all circumstances they will require the same 
number of seats. Looking at it from the standpoint of expenditure, it is 



Retardation and Physical Defects 187 

just as plain that it will cost fully as much to teach them, whether they 
are well along in their grades and studies, or far behind. 

The specific case mentioned of the child who takes ten years to com- 
plete the eight year covu-se sounds convincing, and the argument is 
indeed valid when this actually happens. The trouble is, however, that 
the case mentioned does not represent the average or even a common 
case. In practice the child — and he is typical of a far larger number 
than the general public commonly supposes — does not take ten years to 
finish an eight year course. He simply drops out without finishing. 

In stating these aspects of the problem it is not at all our purpose to 
minimize the evils of retardation or to deprecate the benefits to be gained 
through medical inspection; but cost and overcrowding are not evils of 
retardation. Financial economies are not directly effected through 
medical inspection, and "part time" is not related to the problem. 
" A penny saved is a penny earned " only when the saving is direct. In 
the case of medical inspection the economies effected are the indirect 
ones of securing greater educational returns for the expenditure of public 
funds expended to support the schools, and the still more indirect saving 
effected by bringing about conditions which will render the future 
citizens of the state more efficient. 

The fact that many of the children of the pubUc schools never reach 
the eighth grade and, therefore, do not obtain the eight years' education 
which the common school system provides, long known to educators, 
has of recent years received considerable attention through efforts to 
measvu-e the extent of this tendency and to discover, if possible, its under- 
lying causes. These efforts have been more or less scattered, but the 
appearance of such discussions in different parts of the country indicates 
a growing feeling among educators that these aspects of our school 
administration deserve more attention than they have hitherto received. 
From the standpoint of a comprehensive study of the problem of retar- 
dation it is quite true that the literature of the subject is still in its infancy, 
but there have been contributions to it in various quarters which have 
thrown considerable light upon the subject in its various aspects. 

To a considerable extent the treatment of the subject has been statis- 
tical, and one might say more or less unconscious of the large problems 
which are involved in it. It appears in this form in the reports of vari- 
ous school systems which print tables showing the number of pupils 



i88 Medical Inspection of Schools 

of each age in the several grades, indicating most clearly that the popula- 
tion of a grade is not homogeneous, but is composed of many elements. 
A few facts gathered from various cities were published in the report of 
the U. S. Commissioner of Education for 1903-04. This, again, is 
one of the factors which receives consideration in Dr. Edward L. Thorn- 
dike's publication on "The Elimination of Pupils from School," pub- 
lished by the U. S. Bureau of Education as Bulletin No. 4, 1907. The 
tentative considerations foimd in the report of the Commissioner of 
Education of the State of New York for 1908, in connection with his 
discussion of industrial education, will receive further elaboration in the 
report now in preparation. Perhaps the most useful source of informa- 
tion is the "Psychological Clinic," founded by Dr. Lightner Witmer, of 
the University of Pennsylvania, now in its second volume. It not only 
contains individual studies of abnormal children, but also several im- 
portant essays on the extent, not only of abnormality, but also of that 
lesser degree of mal-adjustment to which the term "retardation" is 
applied in various school systems. Attention is especially called to 
studies of conditions in Wilmington and Camden by the superintendents 
of schools in each of these cities, and to more comprehensive articles on 
"The Retardation of the Pupils of Five City School Systems," by Dr. 
O. P. Cornman; and "Some Further Considerations upon the Retarda- 
tion of the Pupils of Five City School Systems," by Dr. R. P. Falkner, 
in which the conclusions of Dr. Cornman are in part corrected and in 
large measure expanded. 

In all of the foregoing no doubt has been cast upon the validity of 
the basal argument that physical defects have a great and important 
influence on school progress. Public discussion has brought this matter 
into great prominence dm'ing recent years. The physical examinations 
that have been made have demonstrated that many children have not 
the healthy bodies that we have been taught to believe are the necessary 
accompaniments of sound minds. It is certainly disquieting to read that 
two-thirds of the school children of New York City have physical defects, 
and the inference has frequently been drawn that we have in this fact 
the explanation of backwardness in our schools. To be exact, we have 
one cause, not the cause. Among other factors must be reckoned, for 
example, late entrance, irregular attendance, mental dullness, transfers, 
ignorance of the English language, the "lockstep" in promotions. 



Retardation and Physical Defects 189 

To what extent do physical defects cause backwardness? We do 
not know. We do know that we have here a fruitful field for investiga- 
tion. Such limited studies as have so far been made to ascertain the 
quantitative relationship between physical defects and backwardness 
have shown a much smaller causal relation than has been assumed and 
proclaimed by those advocating the physical examination of school 
children. Some of the best work that has been done on this problem 
is that of Dr. Walter S. Cornell, of the Medical Department of the Uni- 
versity of Pennsylvania. The results of some of his investigations were 
published in an article in the "Psychological Clinic" of January 15, 
1908. Among 219 children of both sexes from six to twelve years old 
in one school in Philadelphia, he found the following results : 

Average Per Cent. 
IN Studies. 

Normal children 75 

Average children 74 

General defectives 72.6 

Children having adenoids and enlarged tonsils 72 

In another investigation the children of five schools were examined 
for physical defects. They were divided into so-called "exempt" 
children, or those whose work had been so thoroughly satisfactory that 
they were advanced to higher grades without examination, and "non- 
exempt," or those whose work was less satisfactory. The following 
were the results : 

Exempt. Non-Exempt. 

Children examined 907 687 

Per cent, defective 28.8 38.1 

Still another examination was conducted in one school to determine, 
if possible, the degree of harmful influence of defects of the nose and 
throat. The results follow : 

Bright Dull Dullest 

Children. Children. Children. 

Nimaber examined 89 32 29 

Having nose or throat defects. .10 9 9 

Percent ii.i 28.1 31 

In an article published in the New York Medical Journal of June i, 
1907, Dr. Cornell gives some results of a study of the effect of eyestrain 



iQO Medical Inspection of Schools 

on school progress. In this investigation the relationship of poor 
vision to scholarship was studied in 219 children. The results are 
expressed in the percentages obtained by the children in arithmetic, 
geography, and spelling. 

Children With: Arithme- Geography. Spelling. Average. 

TIC. 

Normal vision 79 69 76 75 — 

Fair vision 70 71 77 73 + 

Bad vision 66 70 71 69 

It is, of course, to be noted that these investigations were conducted 
with a comparatively small number of cases. Moreover, the results ob- 
tained above represent only a very small part of the careful and pains- 
taking studies conducted by Dr. Cornell. The conclusion that he 
draws from his studies is that the educational result in our public schools 
suffers a discount of about 6 per cent, in the case of the physically 
defective children, as well as a waste of time rightfully belonging to the 
normal children. 

Diuring the school years 1904-5 and 1905-6 very extensive investiga- 
tions have been conducted in the city of Camden, N. J., by Superintendent 
of Schools James E. Bryan. The results are reported at length in the 
annual report of the Board of Education of the city of Camden, N. J., 
for the year ending June 30, 1906. In all, 10,130 children of both 
sexes were examined. From these were selected 2,020 children of 
excessive age for their respective grades, counting as of excessive age 
those who were at least one year more behind their grades than the 
standards commonly used in similar discussions. A careful attempt 
was made to classify the causes for the backwardness of these 2,020 
pupils in their school studies. The causes assigned in the classification 
were: 

1. Age upon starting in school, 

2. Absence, 

3. Slowness, 

4. Dullness, 

5. Health, 

6. Physical defects other than sight and hearing, 

7. Mental weakness. 

Under these seven reasons for excessive age the 2,020 children were 
distributed as is shown in the following table: 



Retardation and Physical Defects 

Excessive age due to: 



191 

















Defects 






Number 

Ex- 
amined. 


Age Upon 
Starting. 


Absence. 


Slow- 
ness. 


Dull- 
ness. 


Health. 


Other 

than 
Sight and 
Hearing. 


Mental 
Weak- 
ness. 






Per Cent. 


Per Cent. 


Per Cent. 


Per Cent. 


Pel Cent. 


Per Cent. 


Per Cent. 


Boys . . . 


1081 


20.2 


29.4 


19.8 


12. 1 


7-4 


3-6 


4.6 


Girls... 


939 


22.4 


27-5 


22.4 


II.9 


12. 1 


4.4 


2.6 


Total 


2020 


21.2 


28.5 


21 


12 


9.6 


3-9 


3-7 



Whether the causes assigned have sufficient definiteness, or whether 
the underlying assumption that in each case there is a single cause 
be correct, need not be considered here. For the purposes of the present 
discussion, two points in regard to this table are significant: First, 
that the results of the Camden investigation decidedly support the con- 
tention that physical defects constitute a cause, but not the cause of 
retardation; secondly, that the bearing of physical defectiveness on 
school backwardness does not appear to be very great. Under the 
caption "Health" it appears that bad health was assigned as a reason 
for backwardness in 7.4 per cent, of the cases of the boys and in 12.1 
per cent, of those of the girls. Physical defects other than sight and 
hearing were assigned as reasons for excessive age in 3.6 per cent, of 
the cases of the boys and 4.4 per cent, of those of the girls. 

The foregoing illustrations, while they point in the same direction, 
namely, that physical defect is only one cause of backwardness, and 
perhaps not so prominent as has frequently been assumed, show at the 
same time the paucity of the data directly bearing on these points. 

In view of this scarcity of data, attention may be called to some 
preliminary results of a more comprehensive investigation now in pro- 
gress, but still incomplete. During May and June of 1908 the authors 
of this volume have conducted an investigation into some conditions 
existing among children in fifteen schools of New York City in the 
Borough of Manhattan. The total membership of the schools is some- 
thing over 20,000 and it is almost equally divided among boys and girls. 
The schools themselves are located in different sections of the city, 
from the lower East Side to the Bronx. The school records of all of 
these pupils have been gathered and a careful study undertaken to 
determine, if possible, conditions bearing on the phenomena of retarda- 



192 



Medical Inspection of Schools 



tion. For the purposes of the study, pupils have been divided into two 
groups : normal age and above normal age. All pupils in the i A grade 
(lower first) who at the end of the school year are 8^ years old or younger 
are considered of normal age, those older than 8^ of above normal age. 
In the I B grade (upper first) 9 years marks the limit of the normal age 
group and those older are considered above normal age. In the 2 A 
grade (lower second) the limit is 9^, in the 2 B (upper second) 10, and 
so on up to 16 years of age in the 8 B grade (upper eighth). 

In the endeavor to find out the relation between physical defect 
and retardation, the records of all pupils who have been examined by 
the physicians of the Board of Health have been carefully compiled 
and studied. Among the 20,000 children, 7,608 have had physical 
examinations. As the results of this study are to be fully presented 
in a separate report, it has been thought best to give here as original 
data merely the tables showing the distribution of these pupils by grades 
and defects, and by ages and defects. The derivative tables are all in 
terms of percentages, in order to render them more clear, and the results 
are given by full grades rather than by half grades for the same ptupose. 
Tables A and B present the original data. 

TABLE A.— DISTRIBUTION OF PUPILS BY GRADES AND DEFECTS 









@«5 




^g 















No.Ex- 


H 





Defec- 
tive 


H S 


Defec- 
tive 


Sri 


Ade- 


Other 
De- 


Total 
De- 





AMINED. 






Vision. 


Op5 


Teeth. 


H 3 

ps 


noids. 


fects. 


fects. 


lA.... 


678 


104 


288 


22 


141 


427 


277 


142 


120 


1,417 


iB 


1,151 


17s 


503 


39 


290 


749 


454 


293 


191 


2,519 


2A 


951 


102 


364 


159 


252 


660 


359 


275 


194 


2,263 


2B.... 


788 


-^33 


274 


193 


155 


416 


253 


164 


108 


1,563 


3A..- 


663 


96 


183 


153 


III 


358 


177 


98 


79 


1,159 


3B- — 


620 


119 


107 


128 


55 


350 


163 


59 


93 


955 


4A.... 


533 


139 


52 


137 


52 


227 


100 


57 


75 


700 


4B.... 


531 


152 


59 


138 


40 


209 


127 


71 


81 


725 


SA— - 


338 


"5 


48 


86 


29 


lOI 


65 


28 


22 


379 


SB.... 


299 


122 


5 


72 


13 


97 


41 


15 


14 


257 


6A.... 


314 


122 


II 


84 


48 


91 


38 


10 


31 


313 


6B.... 


167 


55 


7 


34 


12 


64 


25 


II 


13 


166 


7A.... 


212 


55 


8 


56 


31 


76 


24 


16 


28 


239 


7B.... 


159 


69 


12 


44 


12 


17 


30 


3 


17 


^2,5 


8A.... 


134 


27 


II 


38 


8 


64 


II 


4 


15 


151 


8B.... 


70 


19 


7 


28 


3 


7 


15 


2 


5 


67 




7,608 


1,604 


1,939 


1,411 


1,252 


3,913 


2,159 


1,248 


1,086 


13,008 



Retardation and Physical Defects 



193 



TABLE B.— DISTRIBUTION OF PUPILS BY AGES AND DEFECTS 









Q . 




gg 




Q 

S"5 








Ages. 


No. Ex- 


bB 





Defec- 
tive 


P 


Defec- 
tive 


HZ 


Ade- 


Other 
De- 


Total 
De- 




amined. 




2 2 
^0 


Vision. 


Ppq 


Teeth. 


« 


noids. 


fects. 


fects. 


5--- 


9 


2 


6 




4 


4 


I 


I 


2 


18 


6.... 


586 


100 


231 


24 


124 


37« 


23s 


135 


105 


1,232 


7.... 


1,286 


173 


530 


81 


321 


850 


508 


322 


210 


2,828 


8.... 


1,197 


169 


427 


210 


241 


728 


439 


259 


188 


2,492 


9---- 


1,019 


i«5 


286 


206 


166 


567 


290 


188 


136 


1,839 


10 


911 


202 


178 


228 


118 


453 


209 


124 


127 


1,437 


II 


«39 


219 


132 


201 


103 


3SS 


177 


q8 


109 


1,175 


12 


663 


199 


bS 


176 


70 


222 


128 


ss 


S7 


806 


13.... 


510 


163 


35 


121 


SO 


182 


84 


33 


67 


572 


14 


393 


125 


26 


109 


37 


112 


60 


23 


37 


404 


15.... 


144 


S3 


10 


37 


13 


45 


21 


S 


10 


141 


16.... 


42 


12 


5 


IS 


4 


15 


7 


I 


6 


53 


17.... 


7 


2 


I 


2 


I 


2 




I 


2 


9 


18...- 


2 


.. 


I 


I 




.. 


.. 






2 




7,608 


1,604 


1,939 


1,411 


1,252 


3,913 


2,159 


1,248 


1,086 


13,008 



Among the 7,608 pupils, 6,084 fell within the normal age group and 
1,524 in the above normal age group. The following table shows the 
percentage of physically defective pupils in each group by grades : 

Normal Age. Above Normal Age. 

Grade. Per cent. Per cent. 

defective. defective. 

1 85 81.3 

2 86.8 84.5 

3 83.2 83.3 

4 71-6 74-7 

5 63.8 60.2 

6 63.8 61.7 

7 68.2 60.2 

8 77-1 75 

Total 79.8 74.9 

Of course, the immediately striking feature of this table is that 
nearly 80 per cent, of the normal age children are found to have physical 
defects, while only about 75 per cent, of the above normal age children 
are defective. This feature was an unlooked for surprise to the inves- 
tigators. 

The second noteworthy point is that the percentage of defective 
children in the lower grades is decidedly greater than in the upper 
grades. It is to be remarked^ too, that the percentage of defectives 
13 



194 Medical Inspection of Schools 

in the first grade would have been decidedly greater than that in the 
second grade had it not been for the fact that practically no children 
are tested for defective eyesight in the first grade, thereby decidedly 
reducing the percentage of defectiveness. It is likewise true that the 
seventh and eighth grades show a much higher per cent, than would 
normally be the case. This is due to the facts that the figures for the 
seventh and eighth grades are almost exclusively. for one school having 
' a high percentage of defectives, and for comparatively small numbers 
of cases. The reason for this is that in rnpst schools no physical ex- 
aminations were made in the upper grades. 

Our investigations lead us^to believe that under normal conditions 
physical examinations as now conducted in New- Yorls:: City would 
show — if the eyesight of children in the first grade could be tested — a 
percentage of defectives of about 90 in the first grade and that this per 
cent, would gradually reduce through the grades to about 50 in the 
eighth. 

A computation of the average number of defects per child in the 
normal age and above normal age groups gives results not dissimilar 
from those discussed. 

AVERAGE NUMBER OF DEFECTS PER DEFECTIVE CHILD 
Grade. Normal Age. Above Normal Age. 

1 2.5 2.3 

2 2.5 2.6 

3 1-9 2.1 

4 1.8 1.8 

S i-S 1-6 

6 i-S 1-5 

7 IS 1.5 

8 1-3 1-6 

Total 2.1 2.0 

Here again we are confronted by the same phenomena of more 
defects among the children of normal age than among those of above 
normal age, and of the reduction in the number of defects from the 
first grade to the eighth. Of comrse, a question which immediately 
presents itself is whether this unlocked for discrepancy between the num- 
ber of defects among normal age children and the number among those 
of more than normal age is to be accounted for by a consistent pre- 
ponderance of each separate kind of defect among the normal age chil- 
dren, or whether some sorts of defects are more prevalent among those 



Retardation and Physical Defects 195 

of normal age and others among those of greater than normal age. 
Light is shed on this problem by the following table: 

PER CENT. HAVING EACH DEFECT BY DEFECTS 

Normal Age. Above Normal Age, 

Examined loo loo 

Defective 79.9 74.8 

Enlarged glands 26.9 19.5 

Defective vision 23.5 26.9 

Defective breathing 16.7 15.2 

Defective teeth 53.3 43.8 

Hypertrophied tonsils 29.9 22.0 

Adenoids 17. i 13.4 

Other defects 14.1 14.9 

Here we see that each separate sort of defect is found more frequently 
among children of normal age than among those of greater than nor- 
mal age, with two exceptions. These are vision and "other defects." 
The difference in regard to vision is striking. Whereas in the case of 
the other defects there is considerable preponderance among the normal 
age pupils, in the case of vision only 23.5 per cent, are found to be defec- 
tive in the normal age group, while 26.9 of those in the above normal age 
group have defective vision. This at once leads to the suspicion that 
in its relation to retardation, vision does not follow the same rules as do 
other forms of defects. 

Having discovered that the same rules do not uniformly apply 
to all of the several sorts of defects, it becomes worth while to study 
each defect separately by grades and ages. The following table pre- 
sents the per cent, of those of each individual age suffering from each 
defect. 

PER CENT. HAVING EACH DEFECT BY AGES 



Ages. 



6 

7 
8 

9 
10 
II 
12 
13 
14 
IS 



Defec- 
tive. 



82.9 
86.5 
85.8 
81.8 
77.8 

73-8 
69.9 
68.0 
68.1 
63.1 



En- 
larged 
Glands. 



39-4 
41.6 
35-6 
28.0 

19-5 
15-7 
9.8 
6.8 
6.6 
6.9 



Defec- 
tive 
Vision. 



17-5 
20.2 
25.0 

23-9 
26.5 

23-7 
27.7 
25.6 



Defec- 
tive 
Breath- 
ing. 



21. 1 

24.9 

20.1 

16.2 

12.9 

12.2 

10.5 

9.8 

9.4 

9.0 



Defec- 
tive 
Teeth. 



64-5 
66.0 
60.8 
55-6 
49-7 
42.3 
33-4 
35-6 
28.4 
31.2 



Hyper- 
tro- 
phied 
Tonsils, 



40.1 

39-5 
36.6 
28.4 
22.9 
21.0 

19-3 
16.4 
15.2 
14-5 



Ade- 
noids. 



23.0 

25.0 

21.6 

18.4 

13.6 

11.6 

8.7 

6.4 

S-8 

3-4 



Other 
De- 
fects. 



17.9 
16.3 
iS-7 
^3-3 
13-9 
12.9 

13-1 

I3-I 

9.4 

6.9 



196 Medical Inspection of Schools 

A study of the table reveals additional characteristics of the several 
sorts of defect. For instance, under enlarged glands we note that the 
percentage steadily falls from about 40 among six and seven year old 
children to something over 6 among thirteen and fourteen year old 
children. In the case of vision, on the other hand, it increases from 
17 per cent, among eight year old children to 25 per cent, among fifteen 
year old children. The percentage of defective breathing, again, 
decreases somewhat as does that of enlarged glands, falling from about 
25 per cent, among seven year old children to 9 among fifteen year old 
children. A similar steady decrease is found in the case of defective 
teeth, where the percentage falls from 66 among seven year old children 
to 31 among fifteen year old children. A like condition is found in the 
case of h)rpertrophied tonsils. In the case of adenoids the phenomenon 
is even more marked, the percentage falling from 25 among seven year 
old children to 3.4 among those fifteen years old. A steady, although 
not nearly so rapid fall, is also found in the case of other defects. 

In compiling this table, data for the ages of five, sixteen, seventeen, 
and eighteen years have been omitted, for the reason that the number 
of cases under each of these ages is so small as to render them insignifi- 
cant. Percentages of defective vision at the ages of six and seven are 
not given because pupils at those ages are almost without exception 
in the first grades, and as they cannot write, they are not tested for 
defective vision. In all of these cases attention must be called to the 
fact that the decrease in the per cent, of defective children is not due 
to the falling out or leaving school of the children suffering from these 
defects. This might be put forward as an explanation if we had to do 
with children above the age of compulsory attendance, or if the charac- 
teristic decrease did not take place until the age of fourteen or fifteen; 
but such is not the case. We have to do with children of from six to 
fifteen years of age, and the marked decrease begins among the eight, 
nine, and ten year old children, and continues steadily. 

As the older children in general are found in the upper grades and 
the younger children in the lower grades, it is certainly to be expected 
that a tabulation of defects by grades will show the same characteristic 
reductions, and the same exception in the case of vision. This expecta- 
tion is realized in the tabulations made. 



Retardation and Physical Defects 197 

PER CENT. DEFECTIVE BY DEFECTS AND WHOLE GRADES 



Grades. 


Enlarged 
Glands. 


Defective 
Vision. 


Defective 
Breathing. 


Defective 
Teeth. 


Hypertro- 

PHIED 

Tonsils, 


Adenoids. 


I 

2 

3 

4 

5 

6 

7 

8 


43-2 

36.6 

22.6 

10.4 

8.3 

3-7 

5-4 

8.8 


20.2 
21.9 
25.8 
24.8 

24-5 
26.9 

32-3 


23-5 

23-4 

12.9 

8.6 

6.5 
12.4 

5-3 


64.2 
61.8 

55-1 
40.9 
31.0 
32.2 
25.0 
34-8 


39-9 
35-1 
26.5 
21.3 
16.6 
13.0 

14-5 
12.8 


237 

25.2 

12.2 

12.0 

6.7 

4.3 

5-1 

2.9 



Apart from the fact that the eighth grade, for reasons already stated, 
cannot be considered as representative, the table presents many analo- 
gies with the preceding. The percentage of defects dwindles as the 
grades advance, though here again vision stands in a class by itself, 
increasing rather steadily with the higher grades. 

The foregoing tables have shown clearly the fact that age is the 
important factor in considerations having to do with the percentage 
of physically defective school children. It is evident that it is not 
enough to say merely that in a given city 66 per cent, of the pupils are 
found to be physically defective to a greater or less extent. We need 
to know the percentage of defectiveness for each separate defect and 
something of the age of the children. It is evident that if vision were 
omitted, the general percentage of defectiveness might be expected to 
be great if examinations were conducted among the lower grades, and 
comparatively small if they were conducted among the upper grades. 

The same would, of course, be true if the results were tabulated 
by ages rather than by grades. For instance, in the investigation in 
point a computation was made to find the number of defects per hundred 
children in each grade, omitting vision and defective teeth, and basing 
the calculation solely on cases of enlarged glands, defective breathing, 
hypertrophied tonsils, and adenoids. The computation resulted as 
follows : 



Grades 



Defects per 

100 

Children. 



Grades. 



.130 
.120 
• 74 
■ 52 



Defects per 

100 

Children. 

38 

35 

36 

29 



iqS Medical Inspection of Schools 

The same striking falling off is shown if a similar computation is 
made by ages, instead of by grades. 

Defects per Defects pee 

Grades. ioo Grades. loo 

Children. Children. 

6 123 II 68 

7 131 12 47 

8 114 13 39 

9 91 14 24 

10 69 

It is entirely probable that had the results of the physical examina- 
tions performed in the schools by the physicians of the Board of Health 
of New York City taken into account age and grade, the announced 
results and conclusions would have been very different. Reports on 
the examinations of more than 100,000 school children have been pub- 
lished and the per cent, of defectives has run from 66 to 72. From 
these results it has been argued that as there was no reason to believe 
that these were exceptional children, it might fairly be concluded that 
they were typical of school children in New York and even of children 
throughout the United States. On this hypothesis calculations have 
been based, showing the probable number of children in the United 
States in need of medical, surgical, or dental attention, and of the 
probable number of cases of enlarged glands, defective eyesight, poor 
teeth, adenoids, etc., existing among them. Now, it must be remembered 
that the examinations performed in New York have very largely been 
among the very young children in the first and second grades. As 
these children represent a larger proportion of defectives and very much 
greater percentages of those suffering from such defects as enlarged 
glands, hypertrophied tonsils, and adenoids, it is at once evident that 
they are not only not representative of children in the United States, 
but not even of children in New York or in Manhattan. They are 
representative only of very young school children in Manhattan, and 
it is, to say the least, dangerous to argue anything concerning the number 
of children in the United States having each of the different sorts of 
defects from data published so far by the New York Board of Health. 

Another question which so far has had little attention is that of the 
relation of sex and physical defects. The tabulation of the percen- 
tages of defectiveness by sexes for each kind of defect gives the following 
results : 



Retardation and Physical Defects igg 

PER CENT HAVING EACH DEFECT BY SEXES 

Boys. Gikls. 

Defective 78.5 79.2 

Enlarged glands 32.2 20.3 

Defective vision 15.7 20.8 

Defective breathing 19. i 14.3 

Defective teeth 48.4 53.5 

Hypertrophied tonsils 33.1 24.7 

Adenoids 17.4 15.6 

Other defects 13.6 14.7 

DEFECTS PER CHILD 

Boys. Girls. 

1.8 1.6 

Here again we have some surprising variations; 32.2 per cent, 
of the boys are suffering from enlarged glands, while we fovmd only 
20.3 in the case of the girls. Again, under defective breathing we have 
19. 1 per cent, for the boys and 14.3 per cent, for the girls; while hyper- 
trophied tonsils are present in 33.1 per cent, of the cases among the 
boys and only 24.7 per cent, among the girls. On the other hand, 
the boys outstrip their sisters in regard to vision and teeth. These 
results are derived from the examination of a comparatively large 
number of cases, the boys numbering 3,301 and the girls 4,305. 

The results that have been discussed, showing so consistently as 
they do that retarded or above normal age pupils have fewer defects 
than do those of normal age, furnish food for careful thought. Were 
further data not available, it would certainly be difficult to explain the 
seeming anomaly, but the data showing the percentage of defectives 
by ages and grades are illuminating. We see at once that age is the 
important factor. With the exception of vision, the percentage of 
pupils found to be suffering from each separate sort of defect decreases 
rapidly as age increases. Naturally, similar conditions are found when 
children of upper grades are compared with those of lower grades. 

It is evident that we have here a field for many further interesting and 
important investigations. Without entering into any one of them, 
however, we are confronted by one consideration of prime importance, 
which is that dejects decrease with age. 

The importance of this on all investigations into the influence of 
physical defects on school progress is at once evident. Whether the 
term ''retarded" is used to express a condition or an explanation, it 



200 Medical Inspection of Schools 

will always follow from the definition itself that retarded children will 
be older than their fellow-pupils in the same grades. This condition 
will exist, whether time in grade or an arbitrary age dividing-line be 
taken as the criterion for separating pupils into "retarded" and "not 
retarded," or "normal age" and "above normal age" groups. In any 
case it will always be true that the "backward pupils" will be the older 
pupils. 

Now, the older pupils are found to have fewer defects. This is true, 
whether they are behind their grades or well up in their studies. There- 
fore, it is not surprising that we find that 80 per cent, of all children of 
normal age have physical defects more or less serious, while only 75 
per cent, of those of above normal age are found to be defective. This 
does not mean that pupils with more physical defects are brighter 
mentally. It simply means that those who are above normal age are 
older, and that older pupils have fewer defects. 

Why this should be so it is not easy to explain. It is probable 
that we have here a condition brought about by a number of influencing 
factors. In the first place, it must be remembered that the higher 
grades are to a certain extent made up of the survivors of the more fit. 
Those who reach the higher grades are at least to some extent made up 
of the brighter, the more ambitious, the more physically fit, those of 
higher social standing, and those whose parents are in better economic 
circumstances. If the child whose physical defects and mental dullness 
render him exceedingly slow in his school studies leaves school at the 
earliest possible moment permitted by the compulsory education laws, 
or even anticipates that moment, he naturally is not present to be counted 
among the older children or those in the higher grades. This factor, 
while undoubtedly operative, is probably not one of comparatively 
great importance. 

A second consideration, and one of probably far greater weight, is 
that children do actually outgrow their defects. No other conclusion 
seems possible as an explanation of such great falling ofi as we have in 
the case of enlarged glands, with which 40 per cent, of the six year old 
children suffer, but which are foimd present in only 12 per cent, of the 
sixteen year old ones; or in that of defective breathing, where the 
reduction is from 21 to 10 per cent.; or in that of adenoids, with a fall 
from 23 to a little over 2 in the same years. Even in the case of defective 



Retardation and Physical Defects 201 

teeth it is found that nearly 65 per cent, of the six year old children are 
included among those needing attention, and only 35 per cent, of the 
sixteen year old ones. Of course, in this connection it must be remem- 
bered that the older children have their permanent teeth, and tmdoubtedly 
too a much larger proportion of them have received dental attention. 

In studying the problems of school progress and physical defects, 
we must not forget that school success is to only a limited extent a true 
measure of real ability. It may often be rather an indication of adapta- 
bility and docility. Indeed, it would not be surprising to find that the 
child of perfect physical soundness and exuberant health had so many 
outside interests as to render him not particularly successful in school 
work, and that he found the rigid discipline of the schoolroom so irk- 
some as to cause him to fail of approbation by his teachers. 

It is, of course, obvious that this whole subject of the relation of 
physical defects to school progress is one of great importance and one 
which will require a great deal of painstaking investigation and careful 
study. Nevertheless, from the brief data here presented a few conclu- 
sions of value may be drawn. Among them are the following: 

(i) Successful medical inspection results in indirect, 
not direct, financial economies. 

(2) It does have an effect on the problem of retardation, 
but does not affect accommodation and "half time." 

(3) Since our investigation shows that defects decrease 
with age, statistics dealing with physical defects among 
school children are not significant unless they are presented 
in terms of grades and ages. Most defects decrease with 
age, and backward or retarded children have fewer defects 
than those of normal age because they are older. 

(4) Physical defects constitute a cause, not the cause, of 
retardation. 

The foregoing conclusions — so different from those which have 
been emphasized in current discussion — must be briefly examined with 
respect to their significance for the general problem of medical inspection. 

Our first conclusion is that successful medical inspection results 
in indirect, not direct, financial economies. There is an economy 
which means the abstention from expenditure. There is another 



202 Medical Inspection of Schools 

economy which means the production of greater efficiency. The 
economies effected by medical inspection are of this second or indirect 
sort. While they cannot be measured in dollars and cents, they are 
nevertheless far-reaching and important. Everyone brings into the 
world a certain capital of mental ability and physical soundness. On 
these his value to the state will depend when he is grown. Any reason- 
able expenditure which wiU result in their enhancement is in the end an 
economical expenditure of public fimds to promote the public welfare. 

Our second conclusion is that physical defects are related to the 
problem of retardation, but not to that of accommodation. Measured 
in terms of school progress, we naturally expect the sound and healthy 
child to advance further than the physically defective one. We must 
face the fact that the school period is brief and that its effectiveness 
largely depends upon how far the child advances. Indeed, in the vast 
majority of cases it depends upon how far the child advances by the 
time he reaches the age of fourteen. Our studies of the problem of 
retardation lead us to the conclusion that the greatest factor affecting 
the problem of the child's progress through the grades is that of regular 
and continuous attendance. Any influence which tends to reduce 
absence results in an increased use of school facilities, and so in greater 
economy, a higher degree of efficiency, and better results, as measured 
by educational standards of progress. Medical inspection, in banishing 
contagious diseases from the schools and in preventing or removing 
physical defects, has a large and important influence in bringing about 
this greatly to be desired result. 

Conclusions three and four have to do with the statistical aspects 
of the problem. The evidence of current statistics on the need for 
physical inspection is twofold. It proves that physical defect is wide- 
spread. It enforces thereby the conclusion that there would be a gain 
in many respects by the elimination of such defects as are capable of 
prevention or removal by medical science. 

On the other hand, current statistics do not establish physical 
defects as the cause of retardation. Under the broad definition of the 
former it embraces, say 80 per cent, of the school population — retarda- 
tion say 20 to 40 per cent. Hence it is clear that there must be cases 
of defects among the non-retarded. If all the retarded were defective, 
we should have — were 20 per cent, retarded — 100 per cent, defective; 



Retardation and Physical Defects 203 

and among the non-retarded 75 per cent defective. But some of the 
retarded are not defective. Their retardation is due to other causes. 
Hence there must be a certain per cent, of physically normal children 
among the retarded. All of these facts tend to equalize the percentage 
of defectives among the retarded and non-retarded. 

It must not be inferred that physical defects exercise no influence 
upon school progress. They undoubtedly do, but we have not yet 
discriminated among physical defects. We group together all kinds. 
Some have a direct bearing, others none at all. Defective hearing 
undoubtedly exercises an important influence on a pupil's success in 
school, but the fact that a child has a club-foot has no such significance. 
That we are unable to measure by statistical methods the influence of 
physical condition upon school progress is far from proving that such 
influence does not exist. 

On the other hand, our statistical results show most plainly that 
medical inspection and school administration must be more closely 
related and interlocked. The medical inspector must have a greater 
comprehension of school problems and his work must be adjusted as it 
has not been heretofore if it is to contribute to the solution of these 
problems. 



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ings, International Congress, Chicago, 1893, page 50. 

"Observations of the Relation of Physical Development to Intel- 
lectual Ability Made on the School Children of Toronto, 
Canada." Science, New Series, 1896, IV, pages 156-9. 

Williams, Linsly R. : "A Plea for the Physical Examination of all 
School Children." Joiu". of Amer. Med. Asso., Nov, 16, 1907. 

Wingate : "National PubHc Health Legislation." North American 
Review, Nov., 1898, Vol. 167, pages 527-533. 



Bibliography 215 

Wintsch, C. H. : "Medical School Inspection." North American 
Journal of Homeopathy, 51: 210-7. 

Witmer, Lightner: "The Hospital School." Fed. Clinic, Oct. 15, 
1907, i: 138-46. 

Wolfe : "Defects of Sight." Northwestern Monthly, July, 1897, pages 

35-9- 
Wood : " Kindergarten and Primary Grade Work in the Public Schools 

and Its Influence on the Eyesight." Bulletin of the Amer. 

Aca. of Med., Oct., 1898, III, pages 539-44. 

Worrill : " Deafness among School Children." Transactions of the 
Indiana State Medical Society, Indianapolis, 1883, pages 

25-33- 
Wyche, G. : " Inspection of School Children, with Special Reference to 
Ear, Nose, and Throat." St. Louis Med. Rev., May 4, 1907. 

Zirkle, Homer W. : "Medical Inspection of Schools." Investiga- 
tions of the Dept. of Psychology and Education of the Uni- 
versity of Colorado, June, 1902. 



ADDITIONAL REFERENCES 

American Academy of Medicine, Vol. Ill, Oct., 1898. 

"Brief Statement of the Results obtained by the Commissioner of the 
British Dental Association appointed to Investigate the Teeth 
of School Children." British Dental Journal, London, 24: 
809-16. 

"Care of the Eyes." Sanitary Home, June, 1899, P^-ge 79- 

"Causes of Contagious and Infectious Diseases in Schools (The)." 
Rocky Mountain Educator, Dec. 23, 1899; from Indiana School 
Journal. 

"Considerations respecting Medical Inspection in the Public Schools." 
Bulletin of the Amer. Aca. of Medicine, April, 1905, 6: 923-32; 
bibliography, pages 929-32. 

"Cult of Infirmity (The)." Public Opinion, Oct. 19, 1899, page 493; 
from National Review, London. 

"Defective Eyesight." Pop. Sci. Monthly, XXIV, page 357, 

" Defective Vision in School Children." Educational Review V, page 42. 

" Dental Clinic for School Children (New York City)." School Jovurnal, 
Jan. 12, 1907, 74: 54. 



2i6 Medical Inspection of Schools 

"Effects of Study on the Eyesight." Pop. Sci. Monthy, Vol. XXII, 
page 74. 

"Effects of Student Life upon Eyesight." Circular No. 6, Bureau of 
Education, page 2.9. 

"Examination of Railway Employees." Jour, of Amer. Med. Asso., 
Chicago, Oct. 21, 1899. 

"Eye Defects in Students and Children." Ped. Sem., Oct., 1897; 
Science, Jvily 16, 1897. 

"Eye Strain and 'Optic Crutches.' " Medical Herald, July, 1900. 

"Free Eye Glasses for School Children." School Journal, April 27, 
May II, June 29, 1907; 74: 419, 475, 487, 655. Charities and 
The Commons, April 27, 1907, 18: 130-1. 

" Growth of Children." Science, Vol. XIX, pages 256, 281-2 ; Vol. XX, 

pages 351-2. 
" How to Test the Vision." Child Study Monthly, I, No. 6. 
"Hints on the Use and Care of the Eyes." Scribner's XIV, 700. 

"Hygiene for the School Boy and Girl." The Outlook, Dec. 24, 1898, 

1016. 
"Influence of Schools in Accentuating the Spread of Certain Infectious 

Diseases (The)." Lancet, 1898, Jan. 21, page 184; Jan. 28, 

page 256; Feb. 4, page 330, and passim. 

"Inspection of Schools." Educational Times, Dec. i, 1894, pages 

505-11- 
La Medecine Scolaire. (Monthly publication of the Society of Medical 

Inspectors of Schools.) Librarie, Ch. Delagrave, Paris. 

" Medical Examiner for our Public Schools (A) ." Medical Herald, July, 

1900. 
"Medical Inspection of Schools," in "Making a Municipal Budget," 

pages 92-107. Bureau of Municipal Research, New York, 1907. 

Northwestern Monthly, July, 1897. 

"Nutrition. Investigations at the University of Tennessee." Scien- 
tific American, supplement to, March 11, 1899, page 194; also 
Bulletin of the Department of Agriculture, Nos. 29 and 53. 

" Oiu- Eyes and How to Take Care of Them." Atlantic Monthly, 
XXVII, 62, 177, 332, 462, 636. 

Psychological Clinic, Vol. I, No. i, March 15, 1907. (Most scientific 
exponent of the work for backward and mentally retarded 
children.) 



Bibliography 217 

" Relation of Diseases of the Eye to Diseases in General (The)." Medi- 
cal Times, Jan., 1898. 

"School Life and Eyesight." Pop. Sci. Monthly, I, page 766. 

"School Work and Eyesight." Science XII, page 207. 

" Shall We Put Spectacles on School Children ?" Pop. Sci . Monthly, 
XXV, page 429. 

"Sight Training." Literary Digest, Oct. 9, 1898; The Hospital, 
London, March 5, 1898. 

"Statistics on Blindness and Deafness." New York Med. Jour., July 
17, 1897, page 85. 

"Suggestions to Teachers and School Physicians regarding Medical 
Inspection." Special pamphlet, Massachusetts Board of Educa- 
tion, 1907. 

"Tests on School Children." Educational Review, V, page 42. 

Zeitschrift fiir Schulgesundheitspfiege. Edited by Kotelmann 1888-98; 
since that time by Erismann, Hamburg. (This contains many 
articles relative to the progress of medical inspection the world 
over.) 

SCHOOL REPORTS 

Baltimore, Md. : Seventy-eighth Annual Report of the Board of School 
Commissioners, 1906. 

Birmingham, Ala. : Annual Report of the Birmingham Public 
Schools, 1907. 

Boston, Mass. : Annual Report of the Public Schools, 1895. 

Twenty-seventh Annual Report of the Superintendent of Public 
Schools of the City of Boston, 1907. 

Brockton, Mass. : Annual Report of the Superintendent of Schools, 
1907. 

Cambridge, Mass. : Annual Report of Public Schools, 1898. 

Annual Report of the School Committee, prepared by the Superin- 
tendent of Schools, Cambridge, Mass., 1907. 

Camden, N. J. : Annual Report of the Board of Education, 1906. 

Chicago, 111. : Forty-sixth Annual Report of the Board of Education, 

1900. 

Cincinnati, 0. : Seventy-eighth Annual Report of the PubUc Schools of 
Cincinnati, O., 1907. 



21 8 Medical Inspection of Schools 

Cleveland, 0. : Annual Report of the Board of Education, Cleveland, 
O., 1901. 
Annual Report of the Superintendent of Schools, Cleveland, O., 
1907. 

Dallas, Texas : Eleventh Biennial Report of the Dallas Public Schools, 
1906. 

Dayton, 0. : Annual Report of the Board of Education of the City 
School District of Dayton, O., 1907. 

Fall River, Mass. : Annual Report of the City of Fall River, 1907. 

Fitchburg, Mass. : Thirty-fifth Annual Report of the School Committee 
of the City of Fitchburg, 1907. 

Harrisburg, Pa. : Annual Report of the Public Schools of Harrisburg, 
Pa., 1907. 

Hoboken, N. J. : Annual Report of the School Department of Ho- 
boken, N. J., 1907. 

Lawrence, Mass. : Sixtieth Annual Report of the School Committee 
of the City of Lawrence, Mass., 1906. 
Sixty-first Annual Report of the School Committee of the City of 
Lawrence, Mass., 1907. 

Los Angeles, Cal. : Annual Report of the Board of Education of the 
City of Los Angeles, Cal., 1906-7. 

Lowell, Mass. : Eighty-second Report of the School Committee of the 
City of Lowell, and Forty-fourth Annual Report of the Super- 
intendent of Public Schools, 1907. 

Milwaukee, Wis. : Annual Report of the Board of School Directors, 
Milwaukee, 1900. 
Forty-eighth Annual Report of the Board of School Directors of the 
City of Milwaukee, 1907. 

Newark, N. J. : Fifty-first Annual Report of the Board of Education 
of the City of Newark, N. J., 1907. 

Newburyport, Mass. : Annual Report of the School Committee by 
the Superintendent of Schools of the City of Newburyport, 1907. 

New Haven, Conn. : Annual Report of the Board of Education of New 
Haven City School District, New Haven, 1907. 

Newton, Mass. : Annual Report of the School Committee of the City 
of Newton, Mass., 1906. 



Bibliography 219 

New York, N. Y. : Ninth Annual Report of the City Superintendent of 
Schools, City of New York, 1907. 

Northampton, Mass. : Twenty-third Annual Report of the School 
Committee of the City of Northampton, Mass., 1906. 
Twenty-fourth Annual Report of the School Committee of the City 
of Northampton, Mass., 1907. 

Pawtucket, R. I. : School Report, 1901. 

Reading, Pa. : Minutes of the Reading School Board, March 15, 1904. 

San Antonio, Texas : Annual Report of the San Antonio School Board, 
1907. 

Somerville, Mass. : Thirty-sixth Annual Report of the School Com- 
mittee of the City of Somerville, Mass., 1907. 

Syracuse, N. Y. : Fifty-eighth and Fifty-ninth Annual Reports of the 
Department of Public Instruction of the City of Syracuse, 
1906-7. 

Waltham, Mass. : Annual Report of the School Committee and Super- 
intendent of Schools of Waltham, Mass., 1908. 

Wilmington, Del. : Thirty-fourth Annual School Report of the City of 
Wilmington, Del., 1905. 

Yonkers, N. Y. : Twenty-seventh Annual Report of the Board of Edu- 
cation in the City of Yonkers, N. Y., 1907. 



REPORTS FROM BOARDS OF HEALTH 

Briinn, Austria : Dritter Bericht liber die Tatigkeit der stadt. Be- 
zirksartzte in Briinn als Schulartzte, 1903. 
Vierter Bericht liber die Tatigkeit der stadt. Bezirksartzte in 
Briinn als Schulartzte, 1906-7. 

Cambridge, Mass. : Annual Report of the Board of Health, Cam- 
bridge, 1896. 

Everett, Mass. : Fifteenth Annual Report of the Board of Health, 1907. 

Montclair, N. J. : Thirteenth Report of the Board of Health, 1907. 

New York, N. Y. : Working Plan of the System of Medical Inspection 
and Examination of School Children in the City of New York, 
Department of Health, New York, 1906. 

Springfield, Mass. : Annual Report of the Board of Health, 1907. 



220 Medical Inspection of Schools 

OTHER REPORTS 

Commissioner of Education : Report of the Commissioner of Educa- 
tion, 1897-8, Vol. II, "Medical Inspection of Schools," pages 
1489-1512. 

Report of the Commissioner of Education, 1902, "Medical Inspec- 
tion of Schools Abroad," pages 509-526. 

Report of the Commissioner of Education, 1902, "Report of Com- 
mittee on Statistics of Defective Sight and Hearing of Public 
School Children," pages 2 143-2 155. 

Report of the Commissioner of Education, 1906, "Medical Inspec- 
tion of School Children," Vol. I, page 327. 

Detroit, Mich. : Bulletin No. i, Child Study Committee, Detroit 
Public Schools, Dec, 1907. 

Dundee, Scotland : Report on Housing and Industrial Conditions and 
Medical Inspection of School Children. Dundee Social Union, 
Dundee, 1905. 

Dunfermline, Scotland : First Annual Report of Medical Inspection 
of School Children, Dunfermline, 1906. 
Second Annual Report of Medical Inspection of School Children, 
Dunfermline, 1907. 

Edinburgh, Scotland : Report on the Physical Condition of 1400 
School Children in the City of Edinburgh, together with some 
account of their Homes and Surroundings. London, 1906. 

Harrisburg, Pa. : Report of the Special Committee to Investigate and 
Report on Medical Inspection in the Schools. Harrisburg 
School District, Harrisburg, Pa., April 27, 1908. 

London, England : Report of the Education Committee of the London 
County Council, Submitting the Report of the Medical Officer 
(Education) for the Year ended 31st March, 1905. 

Report of the Education Committee of the London County Council, 
Submitting the Report of the Medical Officer (Education) for 
the Year ended 31st March, 1906. 

Report of the Education Committee of the London County Council, 
Submitting the Report of the Medical Officer (Education) for 
the Year ended 31st March, 1907. 

Board of Education. Memorandum on Medical Inspection of 
Children in Public Elementary Schools, under Section 13 of 
the Education (administrative provisions) Act, 1907. London, 
1907, Eyre & Spottiswoode. (Great Britain Board of Educa- 
tion, circular 576.) 

Report of International Committee on Medical Inspection and 



Bibliography 221 

Feeding of Children attending Public Elementary School. 
2 v., London, Wyman & Sons, 1905. 

Lucerne, Switzerland : Bericht und Antrag des Stadtrates von Luzern 
betreffend Errichtung einer Schulpoliklinik. Lucerne, Dec. 8, 
1906. 

Massachusetts (Board of Education) : Sixty-fourth Annual Report 
of the Board of Education, 1899-1900, pages 375-380. 
Seventieth Annual Report of the Board of Education, 1905-1906, 
pages 110-118. "Medical Inspection in the Public Schools." 

New York City : New York Committee on the Physical Welfare of 
School Children. "Physical Welfare of School Children." 
Quarterly of the American Statistical Association, June, 1907. 



Appendix I 



" SUGGESTIONS TO TEACHERS AND SCHOOL PHYSICIANS 
REGARDING MEDICAL INSPECTION " 

Issued by the Massachusetts Board of Education 

Commonwealth of Massachusetts 
State House, Boston, Jan. 23, 1907. 

In order to render the medical inspection required by chapter 502, 
Acts of igo6, effective and uniform throughout the State, His Excel- 
lency Governor Guild appointed a committee to prepare a circular of 
advice to the school physicians of the State. 

This committee consisted of Dr. Henry P. Walcott, Dr. Charles 
Harrington and Dr. Julian A. Mead, representing the State Board of 
Health; Mrs. Ella Lyman Cabot, Mr. George I. Aldrich and Mr. 
George H. Martin, representing the Board of Education; and Dr. 
Robert W. Lovett, Dr. Harold Williams and Dr. W. H. Devine, repre- 
senting the medical profession. 

A sub-committee of this body arranged for conferences with the 
heads of departments and others connected with the medical schools and 
hospitals in and about Boston, and with physicians who have had 
experience in school inspection. These gentlemen have given freely 
of their time and thought, and have furnished to the committee the 
suggestions contained in this circular. 

These suggestions cover the ground included in the clause in section 
5 of the law: "The school committee of every city and town shall 
cause every child in the public schools to be separately and carefully 
tested and examined at least once in every school year, to ascertain 
whether he is suffering from defective sight or hearing, or from any 
other disability or defect tending to prevent his receiving the full benefit 
of his school work, or requiring a modification of the school work in 



Suggestions to Teachers and School Physicians 223 

order to prevent injury to the child or to secure the best educational 
results." 

The Board of Education issues this circular in the assurance that 
it represents the highest professional authority in the specialties covered 
by the law, and commends it to the careful attention of all teachers, 
school physicians and other school officers. 

The following are the subjects treated, with the names of the physi- 
cians who have contributed suggestions: — 

1. Infectious Diseases. — Dr. John H. McCoUom. 

2. The Eye. — Dr. Myles Standish, Dr. Henry B. Chandler, Dr. 
Charles H. Williams, Dr. David W. Wells. 

3. The Ear. — Dr. Clarence J. Blake, Dr. D. Harold Walker. 

4. The Throat and Nose. — Dr. Samuel W. Langmaid, Dr. Algernon 
Coolidge, Jr., Dr. Frederic C. Cobb, Dr. George B. Rice. 

5. The Skin. — Dr. John T. Bowen, Dr. James S. Howe, Dr. George 
F. Harding, Dr. Charles J. White, Dr. C. Morton Smith, Dr. John L. 
Coffin. 

6. Diseases of Bones and Joints. — Dr. Edward H. Bradford, Dr. 
Augustus Thorndike, Dr. Chales F. Painter, Dr. George H. Earl, Dr. 
Robert Soutter. 

7. Children's Diseases. — Dr. Thomas M. Rotch, Dr. John L, 
Morse, Dr. John H. Moore, Dr. Robert W. Hastings, Dr. Edmund C. 
Stowell. 

8. The Teeth. — Dr. Edward W. Branigan, Dr. George A. Bates, 
Dr. Eugene H. Smith, Dr. Samuel A. Hopkins. 

9. Nervous Diseases. — Dr. James J. Putnam, Dr. George L. Walton, 
Dr. Morton Prince, Dr. William N. BuUard, Dr. Edward W. Taylor, 
Dr. John J. Thomas, Dr. Walter E. Fernald. 

10. School Hygiene. — Dr. Henry J. Barnes. 

11. School Furniture. — Dr. Frederick J. Cotton, Dr. R. Clipston 
Sturgis. 

12. School Inspectors. — Dr. George S. C. Badger, Dr. H. Lincoln 
Chase, Dr. Harry M. Cutts. 

George H. Martin, 

Secretary 



224 Medical Inspection of Schools 

DISEASES 
Infectious Diseases 

Diphtheria. — It is a well-recognized fact that nasal diphtheria of a 
mild type without constitutional disturbance is one of the most impor- 
tant factors in causing the spread of the disease, and also that children 
very frequently have profuse discharges from the nose. It therefore 
follows that, in order properly to inspect the public schools, it is impor- 
tant that cultures should be taken from the nose in every case where 
there is a persistent discharge, particularly if there is any excoriation 
about the nostrils. 

The throat should be examined at varying intervals, depending 
upon the physical condition of the children. Any hoarseness or any 
thickness of the voice should cause an examination of the throat. If 
the tonsils are enlarged, if the mucous membrane is congested, if there 
is swelling of the palate, a culture should be taken. These symptoms 
precede diphtheria. 

A child with positive cultures should be excluded from school until 
two consecutive negative cultures at an interval of forty-eight hours 
have been obtained. 

Scarlet Fever. — If there is a sudden attack of vomiting, if there is 
any redness of the throat, if the child complains of headache, if there 
is an unexplained rise in temperature, the child should be isolated at 
once. Any desquamation (peeling of the skin) shoiild be looked upon 
with suspicion. If there are any breaks at the finger tips, if on pressing 
the pulp of the finger there is a white line at the juncture of the nail 
with the pulp of the finger, particularly if this occurs in the majority 
of the finger tips, the child should be excluded from the school. 

A child who has had scarlet fever should not retvim to school until 
the process of desquamation has been entirely completed, and all dis- 
charge from the nose and ears has ceased. 

Measles. — Running from the nose and slight intolerance of light 
may call for an examination of the mucous membrane of the mouth for 
Koplik's sign. Koplik's sign, so called, is the presence on the lining 
membrane of the mouth, near the molar teeth, of ruinute pearly white 
blisters, without any inflammation around them. There may be only 
two or three of these blisters, and they may easily escape detection if the 



Suggestions to Teachers and School Physicians 225 

patient is not carefully examined in a good light. These blisters are 
certain forerunners of an attack of measles. 

No child should return to school after an attack of measles until 
the desquamation is entirely completed, and the child has recovered 
from the intercurrent bronchitis. 

Mumps. — Any swelling or tenderness in the region of the parotid 
glands (situated behind the angle of the jaw) should be looked upon 
with suspicion. It is important to notice any enlargement or swelling 
about Steno's duct (inside the mouth, opposite the second upper molar 
tooth), as this is a very frequent symptom of mumps. 

A child should be excluded from school until one week has elapsed 
after the disappearance of all swelling and tenderness in the region of 
the parotid glands. 

Whooping-cough. — A persistent paroxysmal cough, frequently ac- 
companied with vomiting, no matter whether there is any distinct 
whoop or not, is indicative of whooping-cough. In cases of whooping- 
cough of long standing, even if there has been no distinct whoop, an 
ulcer on the band connecting the lower surface of the tongue with the 
floor of the mouth is found in a certain number of cases. If there is 
no distinct ulceration, there may be a marked congestion of the band. 

As long as there is any cough, the child who has had whooping-cough 
should be looked upon with suspicion. 

Varicella {Chicken Pox). — A few black crusts scattered over the 
body are evidences of an attack of chicken pox. The crusting seen in 
impetigo must be differentiated from that of chicken pox.* 

No child should return to school until all crusts have disappeared 
from the body, particularly from the scalp, for in this region the crusts 
remain longer than elsewhere. 

The Eyes 

[Supplement to circular already issued] 

There are certain children who show normal vision by the ordinary 

tests, yet whose parents should be notified to have the eyes examined. 

These are: (i) children who habitually hold the head too near the 

book (less than twelve to fourteen inches); (2) children who frequently 

* See Diseases of the Skin. 



226 Medical Inspection of Schools 

complain of headaches, especially in the latter portion of school hours; 
(3) children in whom one eye deviates even temporarily from the normal 
position. 

It should be remembered that the following symptoms are at times 
indicative of trouble with the eyes: (i) habitual scowling, and wrinkling 
of the forehead when reading or writing; (2) twitching of the face; 
(3) inattention and slowness in book studies in a child otherwise bright. 



The Ears 
See circular of directions for testing hearing, already in hands of 
teachers. 

The Throat and Nose 

In all cases of acute illness the throat should be examined for the 
presence of the eruption of scarlet fever and measles and for the exuda- 
tion or membrane of tonsillitis and diphtheria, and a culture taken in 
any suspected case of the latter. 

The presence of discharge from the nose should be noted, and 
if it is thick and creamy, a culture should always be taken. In all cases 
of severe hoarseness, with difi&cult breathing, diphtheria should be 
suspected. If the discharge from the nose is only from one nostril, a 
foreign body in the nose should be looked for. 

In cases of chronic nasal obstruction, as evinced by mouth-breathing, 
snoring, continual post-nasal catarrh or recurring ear trouble, the 
presence of an adenoid growth (third tonsil) should be suspected, and 
the child referred for special examination and treatment. As a rule, 
digital examination for adenoids should be made only by the operating 
surgeon. Obviously large tonsils, recurring tonsillitis and enlargement 
of the glands of the neck, suggest the advisability of referring the child 
to the family physician as to the propriety of removing the tonsils. 

Recurring nose-bleed should be referred for special treatment. 

In cases of eczema about the nostrils, a cause may be sought in 
pedicuK capitis (head lice). 

In referring cases for treatment, school physicians, in addition to the 
diagnosis, should state the symptoms upon which the diagnosis is 
based, for the benefit of the family physician or specialist. 



Suggestions to Teachers and School Physicians 227 

Diseases of the Skin 

Scabies {the Itch). — A contagious skin disease, due to an animal 
parasite which burrows in the skin, causing intense itching and scratch- 
ing. The disease usually begins upon the hands and arms, spreading 
over the whole body, but does not affect the face and scalp. Between 
the fingers, on the front of the wrist, at the bend of the elbows and near 
the arm-pits are favorite locations for the disease; but in persons of 
cleanly habits the disease may not show at all upon the hands, and its 
real nature is determined only after a most thorough and careful examina- 
tion. There is a great variation in the extent and severity of this disease, 
lack of personal care and cleanliness always favoring its development. 
Scratching soon brings about an infection of the skin with some of the 
pus-producing germs, and the disease is then accompanied by impetigo, 
or a pus infection of the skin. 

At the present time itch is very common and widespread, and, 
because of the great variation in its severity, mild cases have been mis- 
taken for hives, eczema, etc., the real condition not being recognized, 
and the disease spread in consequence. All children who are scratching 
or have an irritation upon the skin should be examined for scabies. 

It is very important that all infected members of a family be treated 
till cured, else the disease is passed back and forth from one to another. 
It is also important that all underclothing, bedding, towels, etc., things 
that come in contact with the body, be boiled when washed. 

All cases of scabies should be excluded from school until cured. 

Pediculi Capitis (Head Lice). — An extremely common accident 
among children, either from wearing each others' hats and caps, or 
hanging them on each others' pegs, or from combs and brushes. No 
person should be blamed for having lice, — only for keeping them. 

The irritation caused by vermin in the scalp leads to scratching, 
which in turn causes an inflammation of the skin of the neck and scalp. 
The skin then easily becomes infected with some of the pus-producing 
germs, and large or small scabs and crusts are formed from the dried 
matter and blood. Along with this condition the glands back of the 
ears and in the neck become swollen, and may be very painful and 
tender. 

The condition of pediculosis is most easily detected by looking for 



228 Medical Inspection of Schools 

the eggs (nits), which are always stuck onto the hair, and are not readily 
brushed off. The condition is best treated by killing the living parasites 
with crude petroleum, and then getting rid of the nits. With boys, 
this is easy, — a close hair cut is all that is needed; with girls, by using 
a fine-toothed comb wet in alcohol or vinegar, which dissolves the attach- 
ment of the eggs to the hair. All combs and brushes must be carefully 
cleansed. 

Children with pediculosis should be excluded from school until their 
heads are clean. By chapter 383, Acts of 1906, parents who neglect 
or refuse to care for their children in this respect may be prosecuted 
under the compulsory attendance law. 

Ringworm. — A vegetable parasitic disease of the skin and scalp. 
When it occurs upon the skin, it yields readily to treatment; but upon 
the scalp it is extremely chronic. Ringworm of the skin usually appears 
on the face, hands or arms, — rarely upon the body, — in varying sized 
more or less perfect circles. One or more, usually not widely separated, 
may be present at the same time. All ringed eruptions upon the skin 
should be examined for ringworm. 

When the disease attacks the scalp, the hairs fall or break off near 
the scalp, leaving dime to dollar sized areas nearly bald. The scalp in 
these areas is usually dry and somewhat scaly, but may be swollen and 
crusted. The disease spreads at the circumference of the area, and 
new areas arise from scratching, etc. 

Another disease, somewhat like ringworm of the scalp, is known as 
favus, — a disease much more common in Europe than America. In 
this disease quite abundant crusts of a yellowish color are present where 
the process is active. The roots of the hair are killed, so that the loss 
of hair from this disease is permanent, a scar remaining when the condi- 
tion is cured. 

Care must be taken to see that all combs and brushes are thoroughly 
cleansed, and to prevent children wearing each others' hats, caps, etc. 

Children with ringworm should not be allowed to attend school. 

Impetigo. — A disease characterized by few or many large or small 
fiat or elevated pustules or festers upon the skin. The condition is often 
secondary to irritation or itching diseases of the skin (hives, lice, itch), 
and scratching starts up a pus infection. 

The disease most often appears upon the face, neck, and hands; 



Suggestions to Teachers and School Physicians 229 

less often upon the body and scalp. The size of the spots varies very 
much, and they often run together to form on the face large superficial 
sores, covered with thick, dirty, yellowish or brownish crusts. 

The disease is contagious, and often spread by towels and things 
handled. 

Children having impetigo should not be allowed to attend school 
until all sores are healed and the skin is smooth. 

Diseases of the Bones and Joints 
All noticeable lameness, whether sudden or continued, may indicate 
serious joint trouble, or may be due to improper shoes. These cases, 
as well as curvatures of the spine, as indicated by habitual faulty postures 
at the desk or in walking, should be referred for medical inspection. 

Spinal curvature should be suspected when one shoulder is habitually 
raised or dropped, or when the child leans to the side, or shows persis- 
tent round shoulders. 

Complaints of persistent "growing pains" or "rheumatism" may 
be the earliest signs of serious disease of the joints 

Some General Symptoms of Disease in Children which Teacher 
should notice, and on account of v^^hich the children 
should be referred to the school physician. 

Emaciation. — This is a manifestation of many chronic diseases, 
and may point especially to tuberculosis. 

Pallor. — Pallor usually indicates anaemia. Pallor in young girls 
usually means chlorosis, — a form of anaemia peculiar to girls at about 
the age of puberty. It is usually associated with shortness of breath; 
the general condition otherwise usually appears good. Pallor may 
also be a manifestation of disease of the kidneys; this is almost invariably 
the case if it is associated with pufl5ness of the face. 

Ptiffiness of the Face. — This, especially if it is about the eyes, points 
to disease of the kidneys; it may, however, merely indicate nasal ob- 
struction. 

Shortness 0} Breath. — Shortness of breath usually indicates disease 
of the heart or lungs. If it is associated with blueness, the trouble is 
usually in the heart. If it is associated with cough, the trouble is more 
likely to be in the lungs. 



230 Medical Inspection of Schools 

Swellings in the Neck. — These may be due to mumps or enlarge- 
ment of the glands. The swelling of mumps comes on acutely, and is 
located just behind, just in front and below the ear. Swollen glands 
are situated lower in the neck, or about the angle of the jaw. They may 
come on either acutely or slowly. If acutely, they mean some acute 
condition in the throat. If slowly, they are most often tubercular. 
They may also be the result of irritation of the scalp, or lice in the hair. 

General Lassitude, and Other Evidences of Sickness. — These hardly 
need description, but may, of course, mean the presence or onset of 
any of the acute diseases. 

Flushing of the Face. — This very often means fever, and on this 
account should be reported. 

Eruptions of any Sort. — All eruptions should be called to the atten- 
tion of the physician. It is especially important to notice eruptions, 
because they may be the manifestations of some of the contagious 
diseases. The eruption of scarlet fever is of a bright scarlet color, and 
usually appears first on the neck and chest, spreading thence to the 
face. There is often a pale ring about the mouth in scarlet fever, 
which is very characteristic. There is usually a sore throat in connec- 
tion with the eruption. The eruption of measles is a rose or purplish 
red, and is in blotches about the size of a pea. It appears first on the 
face, and is usually associated with running of the nose and eyes. The 
eruption of chicken pox appears first as small red pimples, which quickly 
become small blisters. 

A Cold in the Head, with Running Eyes. — This should be noticed, 
because it may indicate the onset of measles. 

Irritating Discharge from the Nose. — A thin, watery nasal discharge, 
which irritates the nostrils and the upper lip, should always be regarded 
with suspicion. It may mean nothing more than a cold in the head, 
but not infrequently indicates diphtheria. 

Evidences of Sore Throat. — Evidences of sore throat, such as sweUing 
of the neck and difficulty in swallowing, are of importance. They 
may mean nothing but tonsillitis, but are not infrequently manifestations 
of diphtheria or scarlet fever. 

Coughs. — It is very important to notice whether children are cough- 
ing or not, and what is the character of the cough. In most cases, 
of course, the cough merely means a simple cold or slight bronchitis. 



Suggestions to Teachers and School Physicians 231 

A spasmodic cough, that is, a cough which occurs in paroxysms and is 
uncontrollable, very frequently indicates whooping-cough. A croupy 
cough, that is, a cough which is harsh and ringing, may indicate the 
disease diphtheria. A painful cough may indicate disease of the lungs, 
especially pleurisy or pneumonia. A long-continued cough may mean 
tuberculosis of the lungs. 

Vomiting. — Vomiting usually, of course, merely means some diges- 
tive upset. It may, however, be the initial symptom of many of the 
acute diseases, and is therefore of considerable importance. 

Frequent Requests to go out. — Teachers are too much inclined to 
think that frequent requests to go out merely indicate restlessness or 
perversity. They often, however, indicate trouble of some sort, which 
may be in the bowels, kidneys or bladder; therefore, they should always 
be reported to the physician. 

The Teeth 

Unclean mouths promote the growth of disease germs, and cavities 
in the teeth are centers of infection. Pus from diseased teeth seriously 
interferes with digestion, and poisons the system. It causes a lowering 
of vitality and renders mental effort difficult. Diseased teeth, tempo- 
rary as well as permanent, are frequently the cause of abscesses, and 
should be carefully watched and treated. 

Irregularities of the teeth, especially those which make it impossible 
to close the teeth properly, lead to faulty digestion, to mouth-breathing, 
and to other diseases and evils which an insufficient supply of oxygen 
produces. 

The first permanent molars are perhaps the most important teeth 
in the mouth, and are the most frequently neglected, because they are 
so often mistaken for temporary teeth. (It should be remembered 
that there are twenty temporary teeth, ten in each jaw, and that the 
teeth that come at about the sixth year immediately behind each last 
temporary tooth — four in all — are the first permanent molars.) 

The teacher should be on the lookout for pain or swelling in the face. 
When the child keeps the mouth constantly open, an examination of 
the teeth should be made. When symptoms of indigestion occur, or 
physical weakness or mental dullness is observed, the teeth should be 
inspected. It should be remembered that disease of the ears, disturb- 



232 Medical Inspection of Schools 

ances of vision and swelling of the glands of the neck may be caused 
by diseased teeth. 

It should be known that decay of the teeth is caused primarily by 
the fermentation of starchy foods and sugars, and that the greatest 
factor in preventing dental caries is the removal of food particles by 
frequent brushing. Children should be prevented from eating crackers 
and candy between meals, and when possible the teeth should be cleaned 
after eating. Inspection of the teeth by a dentist should be made at 
least once in six months. 

Nervous Troubles and Mental Defects 

Teachers and medical inspectors of the schools should investigate 
children who show certain physical and mental symptoms. Especially 
should they take notice of the presence of these symptoms in a child 
who did not formerly show them. The most important of these are the 
following: — 

I. — Restlessness and inability to stand or sit quietly, in a previously 
quiet child, especially if to this is added irritability of temper and loss 
of self-control, as shown by crying for trifles, or inabihty to keep the 
attention fixed. 

There may also be present quick, twitching movements of the mus- 
cles of the trunk, face, and especially of the hands, fingers, arms or legs. 
If severe, these may cause the child to drop things, render its work 
awkward, or interfere with buttoning the clothes, writing or drawing. 
Such children are often scolded for being inattentive or careless. 

These symptoms are the sUghter ones of chorea (St. Vitus' dance). 
With these should not be confounded other forms of twitching of mus- 
cles, such as the blinking of the eyelids, the slower twitching movements 
of the face or shoulders, or other parts of the body, often called habit 
spasms, which may be due to defects of vision, adenoid growths or 
other reflex causes. These latter cases do not usually need to be with- 
drawn from school work, though often requiring treatment; while the 
former class should be removed from school at once, both for the child's 
sake, and to prevent an epidemic of imitative movements, such as 
sometimes occurs. 

II. — Another class of symptoms requiring investigation are repeated 
faintings, especially if the child's lips become blue; attacks, often only 



Suggestions to Teachers and School Physicians 233 

momentary, in which the child stares fixedly and does not reply to 
questions, or in which he suddenly stops speaking or whatever he is 
doing, and is unaware of what is going on about him. These lapses 
of consciousness may be accompanied also by rolling up of the eyes, 
drooling, or unusual movements of the lips, and often appear like a 
"choking" attack. 

Sudden attacks of senseless movements of various sorts, such as 
twisting and pulling at the clothes or handkerchief, fumbling aimlessly 
at the desk, especially if there is no recollection afterwards of what was 
done, are often another expression of the same conditions. 

Such attacks, particularly if repeated at varying intervals, even 
when not accompanied by complete loss of consciousness, are frequently 
as characteristic of epilepsy as the severe convulsions. 

Epileptic convulsions usually involve the entire body in sharp 
jerking movements, with blueness of the face or lips, complete loss of 
consciousness, and are usually followed by a period of sleep or drowsi- 
ness, and are frequently accompanied by frothing at the mouth, biting 
of the tongue, and occasionally by wetting or soiling of the clothes. 

Another class of convulsions is the hysterical, which are often difficult 
to distinguish. The hysterical convulsion, however, differs from the 
epileptic in the following respects. The hysterical patient often shouts, 
cries or raves, not only previous to but frequently throughout the attack, 
and is often able to reply to questions during the convulsion. The 
epileptic gives a single cry, immediately followed by unconsciousness 
and the spasm. The movements in the hysterical convulsion are often 
accompanied by bowing of the body backward, and very frequently 
simulate intentional or voluntary movements, such as tearing the hair, 
pulling at the clothes, and such things; while the epileptic movements 
are characterized by their jerking or twitching character. The hysterical 
patient, also, in place of a convulsion, may strike an attitude, such as of 
fear or entreaty, often accompanied by raving or singing. This again 
may follow the convulsion, taking the place of, and strikingly contrasted 
with, the almost invariable sleep of the epileptic, which is almost never 
seen in hysteria. Hysterical patients if they fall seldom injure them- 
selves by the fall, as epileptics frequently do. Biting the tongue almost 
invariably indicates an epileptic seizure, as does wetting or soiling the 
clothes when it occurs. 



234 Medical Inspection of Schools 

Cases of epilepsy, whether mild or severe, require treatment, and 
advice as to whether they should be removed from school. Many 
cases do not require to be withdrawn from school, and are benefited by its 
discipline. 

III. — Excessive nerve fatigue, which is shown by irritability or 
sleeplessness, may indicate a neurasthenic condition, that is, a threatened 
nervous breakdown. Such symptoms may be due to irregular habits, 
want of proper sleep, lack of suitable food, poor hygienic conditions, or 
simply from the child being pushed in school beyond its physical or 
mental capacity. 

Excessive fear or morbid ideas, bashfulness, undue sensitiveness, 
causeless fits of crying, morbid introspection and suspiciousness may 
also be symptoms of a neurasthenic condition, and call for investiga- 
tion, and for the teacher's sympathy and winning of the child's confi- 
dence, to prevent developments of a more serious nature. 

This nerve fatigue may result in a child being unable for the time 
being to keep up in its work in school. 

Forgetfulness, loss of interest in work and play, desire for solitude, 
untidiness in dress or person, and like changes of character, are some- 
times incidental to the period of puberty. 

IV. — Mentally defective children in the public schools exhibit cer- 
tain common characteristics. The essential evidence of mental defect 
is that the child is persistently unable to profit by the ordinary methods 
of instruction, as shown by lack of progress or failure of promotion 
through lack of capacity. After one, two or three years in school, 
they are either not able to read at all, or they have a very small and 
scanty vocabulary. One of the most constant and striking peculiarities 
is the feebleness of the power of voluntary attention. The child is 
unable to fix his attention upon any exercise or subject for any length of 
time. The moment his teacher's direction is withdrawn, his attention 
ceases. 

These children are easily fatigued by mental effort, and lose interest 
quickly. They are not observant. They are often markedly back- 
ward in number work. They are especially backward in any school 
exercise requiring judgment and reasoning power. They may excel 
in memory exercises. They usually associate and play with children 
younger than themselves. They have weak will-power. They are 



Suggestions to Teachers and School Physicians 235 

easily influenced and led by their associates. These children may be 
dull and listless, or restless and excitable. They are often wilful and 
disobedient, and hable to attacks of stubbornness and bad temper. 
The typical "incorrigible" of the primary grades often is a mentally 
defective child of the excitable type. They are often destructive. 
They may be cruel to smaller children. They are often precocious 
sexually. They may have untidy personal habits. Certain cases 
with only slight intellectual defect show marked moral deficiency 

The physical inferiority of these defective children is often plainly 
shown by the general appearance. There is generally some evidence 
of defect in the figure, face, attitudes or movements. They seldom 
show the physical grace and charm of normal childhood. The teeth 
are apt to be discolored and to decay early. 

It is a most delicate and painful task to tell a parent that his child 
is mentally deficient. This duty should be performed with the greatest 
tact, kindness and sympathy. It would be a great misfortune for the 
school physician and teacher, as well as for the child, to designate a 
pupil as feeble-minded who was only temporarily backward. 

Temporary backwardness in school work may be due to removable 
causes, such as defective vision, impaired hearing, adenoid growths in 
nose or throat, or as the result of unhappy home conditions, irregular 
habits, want of proper sleep, lack of suitable food, bad hygienic condi- 
tions, etc. Great care must always be used in order not to confound 
cases of permanent mental deficiency with cases of temporary back- 
wardness in school work, due to the causes mentioned above, or those 
described under the head of excessive nervous fatigue. 

In some cases, where the existence of mental defect is in doubt, 
accurate information is usually to be obtained in the early history of 
the child. The time of first "taking notice," the time of recognition 
of the mother, that of beginning to sit up, to creep, to stand, to walk 
and to talk should be learned. Marked delay in development in these 
respects is usually found in all pronounced cases of mental deficiency. 

It may be found useful to require teachers to refer at stated intervals 
to the medical inspectors for examination all children who, without 
obvious cause, such as absence or ill health, show themselves unable to 
keep up in their school work, who are unable to fix their attention, or 



236 Medical Inspection of Schools 

are incorrigible, — though it does not follow that all such cases have 
either physical or mental defects. 

School Hygiene 

The school physician should notice the ventilating, lighting and heat- 
ing of the rooms, and the location of the source of water supply with 
reference to possible pollution. In case pollution of the water supply is 
suspected, application should be made to the State Board of Health 
for an examination of the water. The general cleanKness of the school- 
room is of importance, and the admission of sunhght when possible is 
desirable. 

The Closets. — The school physician, accompanied by the janitor 
of the school, should inspect the toilet rooms, to see if the floors are clean 
and dry, that the bowls of the closets are properly emptied and kept 
clean. (If outhouses are used, a large supply of earth will aid in keeping 
the place in a sanitary condition.) A few simple directions as to the 
cleanliness of the room should be posted in the closets. 

Cups. — The use of one drinking cup for a number of children is to be 
condemned, as tending to spread the infectious diseases from child to 
child. The so-called hygienic drinking fountain, now in more or less 
general use in progressive cities and towns, is to be recommended where 
running water is available. If there is no running water, each child 
should use his own cup. 

School Furniture 

Any proper sort of school furniture should furnish a seat of such 
height that the feet will rest easily on the floor. It should have a desk 
high enough not to touch the knees. It should have a desk low enough 
for the arm to rest on comfortably without much raising of the elbow; 
not, however, so low that the scholar must bend down to write on it. 

The seat should be near enough so that the scholar may reach the 
desk to write on it without leaning forward more than a little, and without 
entirely losing the support of the backrest. The seat should not be so 
close as to press against the abdomen nor near enough to interfere 
with easy rising from the seat. This means a distance of ten and one- 
half to fourteen and one-half inches from the edge of the desk to the 



Suggestions to Teachers and School Physicians 237 

seat back; it also means that the seat must not project under the desk 
more than an inch at most. 

The seat should have a back-rest that will support the "small of 
the back" properly, without having the scholar lean back excessively. 
Wliether it also supports the rest of the back or not is of small conse- 
quence; support of the back carried up to the level of the shoulder 
blades is likely to do more harm than good. 

These are given as the minimum requirements. Whether or not 
regular adjustable furniture is in use, we should not be content with 
less than the accomplishment in one way or another of these primitive 
adjustments. More accurate adjustment is desirable, and less care in 
adjusting would be hard to justify, in the light of our present knowledge 
of the results of faulty attitude. 



Appendix II 



A TYPICAL SET OF EUROPEAN BLANKS AND FORMS 

(Translations of those used in Briinn, Austria) 

FORM I 

Notice to Parents 
As a result of the physical examination of your child 

, which 

examination was made in accordance with the provisions 
of the town council of the city of Brunn, it has been found 
that he (she) is suffering from 

In the interests of your child, as also for the welfare of 
the school, 



is urgently required. 

Briinn, 19 

Medical Inspector 
To 



238 



A Typical Set of European Blanks and Forms 239 



FORM II 
Notice to Parents 



To 

Mr. (Mrs.). 



At the recent medical examination made of your 
child , 

the hair was found to contain vermin. 

In the interests of your child, of your family, and of 
the school, a thorough cleansing is lu-gently requested. 



By Order of the City Council: 
Briinn, 19 . . 



Note: The cutting of the hair is recommended; or rub- 
bing the head with petroleum (taking care of the eyes 
and of proximity to a light), then enveloping the head 
in a closely fitting cap for twelve hours, thereafter 
washing with warm water and soap; or saturating 
the hair with a fatty substance, frequent combings, 
and rubbing with vinegar to eUminate the nits. 



240 



Medical Inspection of Schools 



FORM III 



Health Report 



of son (daughter) of 

Born I 

Vaccinated i School since i . 

Revaccinated i 



Date and School 
Year. 


General 
Constitu- 
tion. 


Ht. 

CM. 


Wt. 

KG. 


Size 

OF 

Chest 

CM. 


Chest and 
Abdomen 
(Tuberculo- 
sis AND Her- 
nia, ETC.). 


Skin Dis- 
eases 
(Parasites). 


Spine and 

Extremities 

(Scrofula, 

Rickets.) 


I 


Winter 
Summer 
















. . 1 


Winter 
Summer 
















III 


Winter 
Summer 
















IV 


Winter 
Summer 
















V 


Winter 
Summer 
















VI 


Winter 
Summer 
















Vll 


Winter 
Summer 
















Vlll 


Winter 
Sum.mer 

















A Typical Set of European Blanks and Forms 241 



(Reverse of Form III) 



Date and School 
Year. 


Eyes 
and Eye- 
sight. 


Ears 

AND 

Hearing. 


Mouth, 

Nose and 

Speech. 


Recommen- 
dations for 
Treatment 
IN School. 
Remarks. 


Notices 

to 
Parents. 


Remarks'of 
Teacher 
(Illnesses, 
Number op 
Hours Ab- 
sent, ETC. 

Instruction 
in, 7). 


1 


Winter 
Summer 














II 


Winter 
Summer 














III 


Winter 
Summer 














IV 


Winter 
Summer 














V 


Winter 
Summer 














VI 


Winter 
Summer 














VII 


Winter 
Summer 














VIII 


Winter 
Summer 















16 



242 



Medical Inspection of Schools 



o 



o 



a> 

w 

o 

a 

H 
«> 

a 
a 



o 



a 
o 



o 
o 



Re- 
marks 

OF 

Teach- 
er. 




w« - 




Recommenda- 
tions as to 
Treatment in 
School (Physi- 
cian's Certifi- 
cate). Remarks. 








Pi 

< 








w >*< „- 

p. Q s 

< 




Para- 
sites. 
Skin 
Dis. 




Chest 

AND 

Abdo- 
men. 




z 
o 

H 
H 
H 

O 

O 

<: 

H 

Z 

M 

o 


1 




a 

1 




O 
O 

o 












o 
§ 


5 




o 





A Typical Set of European Blanks and Forms 243 





ci 




:i 




-o 


> 


> 


s 


nd 


pl^ 


d 







i^ 


T3 




a 




at 



a 
o 



CO S 

*© 
o 

4) 



o 
Pi 

OH 



o 
o 





z 




B 

CL, 




< 

W 

Q 






































No. OF 
Indi- 
vidual 
Examin- 
ations. 




No. OF 
Pupils 
Exam- 
ined. 




f» ,'r, 

2;u 




No. OF 
Visits 

BY 

Physi- 
cians. 







a 



.;2 

t-i 






1 

05 





244 



Medical Inspection of Schools 



FORM VI 



Physician's Report 



Born. 



. School Street. 



General Constitution Mentality 
Chest Organs (Tuberculosis) 
Abdominal Organs (Hernia) 
Spine and Extremities 
Skin (Parasites) 
Eyes, Eyesight 
Ears, Hearing 
Mouth, Nose and Speech 
Remarks 

Physician's Recommendations regard- 
ing Instruction 



Briinn, 19 



Practising Physician 



Note. — ^Physicians are requested to make out the report as carefully 
as possible. The first section, "General Constitution," must 
always be filled out, and according to the category of "good," 
"medium," and "bad," bracketing (chlorosis, tuberculosis, etc.). 
The other sections need only be filled out in case of symptoms. 

A detailed statement in the section, "Remarks," is particu- 
larly desired when questions arise as to absences of the child or 
questions of excuses from lessons and from physical training. 



FORM VII 



Memorandum Blank 



With Reference to Unhygienic Conditions found in School Houses by 
Medical Inspectors 



Date of Visit. 


School. 


Remarks, Suggestions, etc. 









Briinn, 19.. 



Medical Inspector 



I 



A Typical Set of European Blanks and Forms 245 

Questions to Parents or Guardians 

In the interests of the pupil, so that due consideration may be ac- 
corded to him in school, it is requested that careful answers be given. 



Name of Pupil 



During what years of life did sickness occur? 
Name the illnesses. 



Did you observe continued ill effects of such sick- 
ness ? What effects and since when ? 



Has the child sustained injuries of lasting conse- 
quence? When, and what injuries? 



When did the child (a) learn to walk, (b) learn to 
talk? 



Has the child weak eyes, or is he nearsighted? 
Since when and what is the cause ? 



Has the child difficulty in hearing? Since when 
and what was the cause ? 



Is the child suffering from other defects or weak- 
nesses? (Frequent headaches, nose bleeding, 
lassitude, frequent loss of appetite, convulsions, 
nervous irritability, difficiilties in speech, psychic 
peculiarities.) 



Has puberty been reached? Since when? Are 
the periods regular? Are there difficulties? 
What difficulties? 



Does the child regularly partake of alcohol? 
Does he drink beer, wine, tea with rum, and if 
so, in what, quantities? 



A regular system of medical inspection has been 
introduced into the school. Parents or guar- 
dians are, therefore, requested to indicate clearly 
as to whether they grant or refuse their consent 
for the examination of the child by the school 
physician. 



Briinn, 19 



Signature 



246 



Medical Inspection of Schools 



(Individual Report Giving Results of Semi-Annual Physical Examinations During 
the School Life of Eight Years.) 



Health Report 
Name Born. . . 



Vaccinated 



Class 


I 


II 


III 


IV 


V 


VI 


VII 


VIII 


Terms 


I 


2 


I 


2 


I 


2 


1 


2 


I 


a 


I 


2 


I 


2 


I 


3 


Examined (Date) 
General Condition of Body 
Height in cm. 
Weight in kg. 




I. 
Condition 

of the 
Body and 
the Blood 


1. Anaemia 

2. Chlorosis 

3. Scrofula 

4. Enlarged Glands 

5- 




II. 

Osseous 
Structure 


1. Malformation of Skull 

2. Malformation of Sternum 

3. Scoliosis 

4. Deformities of Limbs 

S- 




III. 

Condition 

of Bones, 

Joints, 

and 
Muscles 


1. Chronic Inflammation of the 

Bones 

2. Chronic Inflammation of the 

Joints 

3. Rachitis 

4. Wry-neck 
5. 




IV. 

Skin 


1. Eczema 

2. Psoriasis 

3. Furunculosis 

4. Prurigo 

S- 




V. 

Mouth, 

Throat, 

Nose 


1. Adenoids 

2. Ozena 
3- 




VI. 
Condition 
of Lungs 


1. Asthma bronchiale 

2. Tuberculosis 

3. Chronic Catarrh 




VII. 

Condition 

of the 

Heart 


1. Funktionelle 

2. Malformation, or defective 

heart 

3- 





A Typical Set of European Blanks and Forms 247 





(Reverse of Health 


Report) 
















Class 


I 


II 


III 


IV 


V 


VI 


VII 


VIII 


Terms 


I 


2 


I 


2 


I 



2 


I 


2 


I 


2 


1 


2 


I 


2 


I 


2 


VIII. 

Abdominal 
Organs 


1. Chronic Catarrh of Stomach 

and Intestines 

2. Hemorrhage from Stomach 

3. Nycturia 
4- 

S- 




IX. 

Eyesight 


1. Myopia 

2. Hypermetropia 

3. Weak Eyesight 

4. Twitching of the Eyes 

5. Strabismus 
6. 


- 




X. 

Diseases 

of the 

Eyes 


1. Chronic Inflammation of the 

Conjunctiva 

2. Chronic Inflammation of the 

Cornea 

3. Chronic Inflammation of the 

Eyelids 

4. Trachoma 

5. Scars and Spots 
6. 




XI. 

Hearing 


I. Ability to hear Whisper 
2. 




XII. 
Diseases 
of the Ear 


I. Discharge from Ears 
2. 




XIII. 
Speech 


t. Stammering 
2. Stuttering 




XIV. 
Defects of 
Develop- 
ment 


1. Defective Palate 

2. Inguinal Hernia 

3. UmbiUcal Hernia 

4. Goitre 




XV. 

Nervous 
System 


1. Convulsions 

2. Epilepsy 

3. Paralysis 
4- 

5. Ataxia 

6. Chorea 

7. Abnormal Reflexes, Twitchings 
8. 


- 




XVI. 
Psychic 
Peculiar- 


1. Unusual Irritability 

2. Particular Inclinations 
3- 




ities 










XVII. 
Parasites 


1. Scabies 

2. Pediculosis 
3- 




Condition 
of Teeth 






Develop- 
ment 






Remarks. Absences from school on account 
of illness. Mention them and give dates 
and periods of each sickness. 







248 Medical Inspection of Schools 

FORM I (Dental) 

Briinn, 190 .. . 

Name: Pupil in class 

of school , residing at 

requires prompt dental treatment. If it meets with your 
consent to have him (her) undergo such treatment, it is 
requested that you signify your willingness by signature. 
Treatment is conducted at the expense of the city. 



Medical Inspector School Principal 

Affirmation 
I hereby testify my willingness to have my child..... ^ 

. •« ^ ^ >. ... . .undergo dental treatment. 

Signature: 



A Typical Set of European Blanks and Forms 249 

(Reverse of Form I — Dental) 

Care of the Mouth and Teeth 

Food well chewed is half digested. Badly kept teeth 
hinder mastication; they create a disagreeable odor, and 
are often the cause of interferences with health. Pieces of 
food lodge and decay in carious teeth; and disease germs 
are found in the oral cavity. 

Therefore, from the standpoint of breathing and from 
that of good digestion, the hygiene of the mouth is most 
essential. For this reason the mouth and teeth should be 
rinsed daily, in the morning and in the evening, with clean, 
lukewarm water. The teeth and gums should be cleansed 
with a clean, moistened brush, using as a tooth powder 
finely ground chalk, and by moving the brush up and 
down. Finally the mouth and throat should be rinsed 
throroughly with water. 

Food eaten very cold or very hot, that which is too 
sweet or too sour, as well as food highly spiced, is injurious 
to the teeth. 

The moistening of postage stamps, envelopes, or ink 
spots with the tongue; the putting of the fingers, of play- 
things or any other objects into the mouth; the insertion 
of hard substances, such as a fork, penknife, pen, pin, etc., 
between the teeth may cause great damage. None but 
wooden or quill toothpicks should be used. 

In the case of a diseased tooth, the sooner a dentist is 
consulted, the sooner is it possible to remove the difl&culty. 



250 Medical Inspection of Schools 

FORM II (Dental) 

No Briinn 190 

To Dr 

Dentist 

in Briinn. 

Upon consent having been obtained from the parents of 
pupil in class , school 

located at , for dental treatment of 

their child, you are hereby requested to undertake such 
treatment and to make appointments. 

City Physician 



(Reverse of Form II same as reverse of Form I) 



Appendix III 



RULES ISSUED TO MEDICAL INSPECTORS OF SCHOOLS 

IN CHICAGO, ILL., DETROIT, MICH., AND 

SPRINGFIELD, MASS. 

I. Rules for Medical Inspectors and School Medical Inspectors, 
Department of Public Health, City of Chicago 

Medical Inspectors should familiarize themselves with the City 
Health Ordinances. (Copies can be had by applying to the Secretary.) 

Beginning at 9 o'clock Medical Inspectors will call daily at the 
schools assigned them, and request principals to have all pupils in readi- 
ness for examination who have been absent from school for four con- 
secutive days. The principal will also refer to the Inspector any pupils 
in school who are suspected to be suffering from infectious or contagious 
diseases. 

The examinations will be made at the school. 

The principal of school should have all children to be examined 
sent to a room by themselves where the other pupils will not come in 
contact with them, and where the school inspector can examine them. 

Inspection is to be made in reference to communicable diseases 
and the vaccinal status of pupils only. 

Examinations are to be made for the following diseases: Scarlet 
fever, diphtheria, measles, rotheln, smallpox, chickenpox, tonsillitis, 
pediculosis, ringworm, impetigo contagiosa or other transmissible 
diseases of the skin, scalp and eye. Tuberculosis, when thought to 
be far enough advanced to be a menace to the public health, must be 
reported to the Chief Medical Inspector before excluding the pupil from 
school. 

Scarlet-fever cases must not be allowed to return to school until 
all desquamation is completed, and there is an entire absence of dis- 

251 



252 Medical Inspection of Schools 

charge from ears, nose, throat or suppurating glands and the child and 
premises are disinfected. This requires at least six weeks — severe 
cases eight weeks or longer. 

Diphtheria cases must be excluded until two throat cultures made 
upon two consecutive days show absence of the Klebs-LoefSer bacilli. 
Those exposed to diphtheria should be excluded one week from last 
exposure. 

Measles cases are very infectious in the early stages, and must be 
excluded at least three weeks and longer if there is present bronchitis, 
inflammation of the throat, nose or abscess of the ear. Those exposed 
to measles should be excluded two weeks from date of last expostire. 

Whooping Cough: Cases should be excluded until after the 
spasmodic stage of cough — usually about eight weeks. Whooping 
cough is very infectious in the early stages of the disease. Those ex- 
posed to whooping cough should be excluded two weeks from date of 
last exposure. 

Mumps : Exclude ten days after all swelling has subsided. Those 
exposed to mumps should be excluded three weeks from date of last 
exposure. 

Chickenpox: Exclude until scabs are all off and skin smooth — 
two to three weeks, according to the severity of the attack. 

Rotheln, German Measles: Exclude from school two weeks. 
Those exposed to rotheln must be excluded from school three weeks 
from date of last exposure. 

Cases of tonsillitis must be excluded on the clinical evidence alone, 
and throat cultures made for further diagnosis. 

Cases presenting suspicious throats, but not definite evidence of 
disease clinically, must have throat cultures made, allowed to return 
to their classes until the cultures have been examined, and only excluded 
in case the bacteriologic examination shows exclusion to be necessary. 

In making inspections care must be used to disturb the child as 
little as possible, and throat cultures are to be made only when good rea- 
son therefor exists. 

In making throat examinations, the wooden tongue depressors 
supplied must be used, to the exclusion of all other tongue depressors. 
Each tongue depressor must be used only once and then burned. Asep- 
tic methods must be employed in all examinations. 



Rules Issued to Medical Inspectors 253 

If a child is excluded, brief but sufficient reason therefor must be 
written on the exclusion card. 

Inspectors are forbidden to make any suggestions as to the treat- 
ment or management of pupils who are sick. This is imperative. 

Children recovering from measles, whooping cough, mumps, chicken- 
pox, scarlet fever, diphtheria and smallpox — must not re-enter school 
without a permit from the Department of Health. 

When a pupil is taken sick with an infectious disease in a school- 
room, the pupils in the room must be dismissed, and the room disinfected. 

If smallpox is found in the eruptive stage, the child can be taken to 
his home, if near, and there isolated until the ambulance arrives, or 
isolate in the room where found. In doing this no one should be allowed 
to come near the infected child. 

Children properly vaccinated who have been exposed to small- 
pox need not be excluded from school. Those exposed and not vacci- 
nated must be excluded twenty days. 

Pupils living in apartment buildings, where an infectious disease 
exists, should be excluded from school by the principal. A visit to the 
building by the Inspector will determine who can return to school with 
safety. It depends upon the construction of the building and the 
habits of the inmates whether it is safe to let any from the building 
continue in school. The Inspector must be the judge. Usually if 
families use the same entrance there is some risk, and yet a case can 
be so well isolated and cared for that all others in the building are safe. 
A visit to the building is necessary to determine this. 

All cases of infectious diseases coming under the observation of the 
Inspector which are not properly safeguarded should command his 
attention. 

Give proper instructions to the family, leave the Department cir- 
cular applicable to the case, and take any other measures necessary 
to protect the pubhc health. Investigate all suspected cases of infectious 
diseases in your territory and take proper measures for safeguarding 
against the spread of infection. Make daily reports to the Chief Medical 
Inspector upon blanks provided for the purpose of each case inspected 
or investigated. Beginning Oct. 15, School Medical Inspectors will 
vaccinate free of charge any child or pupil who may apply to them for 
vaccination, and must issue a certificate of vaccination to those entitled 



254 Medical Inspection of Schools 

to the same. The inspectors will vaccinate no child without the con- 
sent of parent or guardian. 

The Department prefers that the family physician should perform 
vaccination; but if the parent or guardian of a child wishes it done by 
the Department the child may be taken or sent to the School Medical 
Inspector or Public Vaccinator, whose duty it then is to vaccinate 
such child and furnish a certificate without charge. 

Examine every school pupil's arm to determine the vaccinal status. 
Any discovered not complying with the vaccination ordinance must be 
excluded from school by the principal. Read the ordinance carefully 
and be governed by it in the matter of vaccination. Inspectors must 
make monthly reports upon blanks furnished for that purpose, giving 
the number of tubes of vaccine received during the month, the number 
of primary vaccinations performed, the number of re-vaccinations 
performed, the number of certificates issued to those previously vaccin- 
ated within seven years and entitled to a certificate without a re-vac- 
cination, the number of attempted vaccinations on primary subject 
resulting in failure to take, and the number of attempts at vaccination 
in previously vaccinated subject resulting in failure to take. 

Inspectors must carry with them a supply of the Department circu- 
lars to hand out for instruction in cases of infectious diseases. The 
circulars are: Information for the family in case of contagious diseases. 
Circulars on prevention of consumption. The Vaccination Creed. 
Special circulars on each of the infectious diseases and warning slips 
to distribute and paste up for the public to read. Spatulas for tongue 
depressors. Culture mediums and outfits for Widal test. 

Additional Duties of School Medical Inspectors 
The city has been divided into eleven districts. A Medical Inspec- 
tor, a Sanitary Inspector and a Milk Inspector is placed in each of these 
districts. Each of these districts is subdivided into nine districts with 
a School Medical Inspector in each of these minor districts. The 
nine School Medical Inspectors will be under the direction of the Medical 
Inspector. Each morning before 9 o'clock the location of the infectious 
diseases reported to the Department will be telephoned to the School 
Inspector in the district from which the case is reported. The Medical 
Inspector will have the same information from the nine districts. The 



Rules Issued to Medical Inspectors 255 

School Inspector will visit all cases reported from his district, see that 
proper isolation is established, determine who from contiguous fiats or 
houses can safely remain in school, and see that the warning card is on 
the door or where it will best serve the purpose of warning any who 
may approach the infected premises. See also that a warning card is 
posted where the milk man who delivers milk will see it, leave the 
Department circulars giving information in cases of contagious diseases 
and distribute and post the small warning leaflet in the near-by neigh- 
borhood and mail a notification card to the principal of school. 

The Inspector notified will take smears in cases of diphtheria to 
determine when the case is ready for termination. When the District 
Medical Inspector has more antitoxin work than he can attend to, the 
School Medical Inspector will aid in this work. When the School 
Inspector is in doubt about a diagnosis he will call upon the District 
Medical Inspector to help in making a diagnosis. The School Inspector 
is to have charge of all infectious diseases in his restricted territory 
and will be held responsible for the work in the territory assigned him. 
The Medical Inspector will be held responsible for the work of the nine 
School Inspectors in his district. To assist the Medical Inspectors three 
diagnosticians have been designated — one on each of the three sides 
of the city. In making inspections and investigations you will observe 
the following instructions: 

Inspectors must keep in close touch with the Department of Health 
so they may be reached without delay when wanted. 

Contagious diseases and suspected contagious diseases reported 
to the Department of Health are assigned to the Medical Inspectors 
and School Medical Inspectors either for inspection or investigation. 

Cases for inspection are those reported by physicians. In these 
cases see that the family receives a copy of the Department "Circular 
of Information Upon the Management of Contagious Diseases," and 
give them such further advice concerning the best methods to pursue 
for preventing the spread of contagion as you deem necessary. 

Especially instruct the family in regard to the length 0} time cases 
should be isolated and impress upon them the necessity of a thorough 
disinfection after the case has terminated. 

Tell them to have their doctor notify the Department when the 
case is free from giving off contagion and the house is ready for disin- 



256 Medical Inspection of Schools 

fection — and not before. Disinfectors are frequently sent to families 
only to find that the patient is still in the contagious stage, especially 
in scarlet fever. This means loss of time to the disinfecting force. 

Notify by postal card provided the principal of every school in the 
vicinity, both public and parochial, during vacation as well as while 
school is in session, whom to exclude from school and take such other 
measures in the case as may be needed to protect the public health. 
You are the judge of whom it is safe to permit to attend school from 
flats or houses contiguous to infected premises. 

If you find the family disregarding the doctor's instructions concern- 
ing isolation, disinfection of excretions, etc., supplement his instructions 
and through your own efforts see that the family observes proper pre- 
cautions. 

If the case is in any way connected with a shop or store, at once 
make the case safe to the public by one of the following plans: 

1. When it is best to do so, the Department of Health will remove 
the patient to a hospital. No one can move a person sick with an 
infectious disease without the consent of the Commissioner of Health. 

2. If the patient remains, the room must be shut off from the store 
by sealing cracks of doors and keyholes with paper and paste. All 
communication between the sickroom and the store must be stopped. 

3. If neither of the above plans is followed the store must be closed, 
the door locked and the public excluded. 

Cases for investigation are supposed cases, such as are reported 
•to the Department through other sources than physicians. These you 
will visit and ascertain the nature of the disease, and if found to be 
scarlet fever, diphtheria, whooping cough or measles, see that the 
attending physician, if there be one, reports the case to the Department, 
or report it yourself by card, as you do in a case where there is no physi- 
cian. Put up a warning card and take the same precautionary measures 
as in cases for inspection. 

Send notices to principals of schools of any and all contagious 
diseases encountered while inspecting and investigating cases. 

Make daily reports to the Department of all cases inspected or 
investigated. 

Endeavor to learn the source of infection in every case: milk sup- 
ply, fruit, infected clothing, or persons, etc., and communicate to the 



Rules Issued to Medical Inspectors 257 

Department any information of interest which you may learn concern- 
ing this subject. 

When notified of a suspected case of smallpox the Inspector must 
go to the case forthwith. An hour's delay may result in many needless 
exposures. 

The following suggestions as to conduct in the presence of smallpox 
should be observed so far as the circumstances of the case will permit 
with safety. The Inspector must supply any deficiency in these instruc- 
tions which the case may demand for the safety of the public. 

When entering a house where there is a suspected case of contagious 
or infectious disease do not remove your hat or overcoat; keep the 
overcoat buttoned. 

Do not shake hands with any one in the house. Do not sit down 
or touch anything in the house and especially avoid touching the patient 
or bed clothing. To expose the patient for examination call upon the 
patient or some one present to remove the clothing for you. When 
leaving the house have some one open the door so as to avoid touching 
any infected doorknob. 

Except to vaccinate the inmates of the house, it is not necessary 
to touch anything about the premises except the floor with the soles of 
your shoes. 

If these precautions are observed there is no danger of carrying the 
disease to others. 

When it is determined the case is one of smallpox, fill out the history 
blank provided for the purpose (Form 2), telephone the information 
to the Department and promptly mail the filled blank to the Chief 
Medical Inspector. 

Telephone instructions as to the disposal of the case, whether an 
ambulance or a carriage is needed, the amount of disinfecting to be done 
and the number of vaccinators needed. 

In filling out the blank secure a list of all who have in any way been 
exposed to the contagion since the first day of the sickness, learn if 
letters or laundry have been sent out from the house and where and to 
whom sent. Give the vaccinal status of those exposed so far as you can. 

It is the duty of the Inspector to vaccinate or see that some other 
medical inspector vaccinates all who are known to be exposed to the 
infection. Do not leave or allow this duty to be done by the "family 
17 



258 Medical Inspection of Schools 

physician." It is the duty also of the Inspector to secure the consent 
of the patient or family for the removal of the patient to the Isolation 
Hospital. Do not leave this duty to the ambulance driver. 

Until the ambulance comes the case must be made safe. If it is 
necessary to police the house to secure safety, do so. After securing 
the prompt vaccination of all exposed it is the Inspector's duty to see 
the exposed every other day for fifteen to twenty days. If the vaccina- 
tion does not take, repeat until it does take. 

If there is doubt about the diagnosis, vaccinate the inmates of the 
house, make the case safe to others and see the patient later. 

A Medical Inspector must be courteous and should be tactful in all 
his relations to cases of smallpox, the same as a doctor should be in 
his private practice. He should be a complete master of the situation, 
able to dispose of complications and duties as they arise, in a proper 
manner. It should not be burdensome to do so, for the reward is always 
present, the consciousness that it is life-saving work. 

Use discretion and secure compliance with the ordinance without 
force. 

This can almost always be done, but if necessary the police power 
can be used to enforce compliance with the law. 

II. Instructions to Medical Inspectors of Public Schools 
Detroit, Mich. 

1. The pupils to be inspected will be referred to the inspectors by 
the principal for two reasons : 

A. Those who have been absent one or more days. 

B. Those in the school whom the teacher may suspect to be 

suffering from communicable diseases. 
These two classes must be kept separate in the reports. 

2. The inspection is to be made with reference to communicable 
diseases only, and pupils are to be excluded for the following diseases: 

Scarlet Fever Mumps Pediculosis 

Diphtheria Smallpox Ringworm 

Tonsillitis Chickenpox Impetigo 

Rotheln Whooping cough Scabies 



Rules Issued to Medical Inspectors 259 

or other communicable diseases of the skin and scalp, and communi- 
cable diseases of the eye. 

3. In making throat examinations, the wooden tongue depressors 
supplied must be used to the exclusion of all other depressors. Each 
tongue depressor must he used only once. Aseptic methods must be 
employed in all examinations. 

4. Whenever a child is excluded, brief but sufl&cient reason therefor 
must be written on the exclusion card. 

5. Medical inspectors will use their own judgment about the accept- 
ance of family physician's certificates. You have the right to ignore 
them if such action is justified by your personal investigation of a case at 
school. 

6. The principal excludes children from school, the inspector 
recommends to the principal exclusions when justified, the principal 
acts accordingly. Do your utmost to maintain harmony and coopera- 
tion with principals. 

7. Be sure and give exclusion cards in every instance, so parents 
will be notified 

8. Remember you have no jurisdiction as inspector beyond the 
threshold of the public schools of your district. DO NOT examine 
pupils at your ofiice or any place outside of the public schools. 

9. Use great discretion in examining pupils. Do not keep them 
waiting any longer than necessary. 

10. On discovery of smallpox, diphtheria, or scarlet fever cases 
notify Health Officer AT ONCE by telephone. Blanks for reports, 
etc., can always be obtained at the Board of Health Building, 233 St. 
Antoine Street. 

11. Report promptly to Health Officer whenever illness or accident 
prevents you from going to your work. 

12. Send in your weekly reports PROMPTLY. 

13. Medical inspectors are paid on the fourth Saturday of each 
month. Checks are at City Hall, office of City Treasurer. 



26o Medical Inspection of Schools 

III. Rules for the Medical Inspection of the Public School 
Children, Health Department, Springfield, Mass. 

Under the authority of the revised laws of the State of Massachusetts, 
the Board of Heakh of this city has arranged a system of medical in- 
spection of pupils attending the pubHc schools. 

The objects of the medical inspection of school children are: (i) 
Identification of all pupils requiring medical care. (2) Prompt ex- 
clusion from school of all pupils suffering from communicable diseases, 
(3) Detection of ailments and diseases other than communicable 
diseases. (4) Detection of defects of sight or hearing or other disability 
injurious to pupils. 

Under the law, the tests of sight and hearing shall be made by the 
teachers, and the necessary rules of instruction, test cards, etc., will be 
distributed as soon as they are ready. 

It is desirable that the Medical Inspector have the use of a room for 
the examination of children. The Medical Inspectors wiU visit each 
school twice weekly, — Monday and Thursday mornings. The Principal 
of the school and the Medical Inspector should agree upon the hour of 
inspection, which should, as far as possible, serve the best interests 
of the two or more schools to which the inspectors are assigned. The 
Medical Inspector will examine such children as are indicated by the 
teachers. 

The following described children should be sent to the Inspector 
at the appointed time: 

A. Every child returning to school without a certificate from the 

Board of Health after absence on account of illness, or 
from unknown cause. 

B. Every child who shows signs of being in ill health, or suffering 

from infectious or contagious disease. 

C. Every child returning to school after having been excluded by 

the Inspector. 

Children showing symptoms of the following diseases are to be 
sent home immediately: 



Rules Issued to Medical Inspectors 261 

Smallpox Diphtheria Mumps 

Scarlet Fever Influenza Scabies 

Measles Tonsillitis Trachoma 

Chickenpox Whooping Cough Ringworm 

Tuberculosis Pediculosis Impetigo contagiosa. 

In case exclusion from school is warranted, the exclusion card is 
to be filled out and put in a sealed envelop and given to the child to take 
home. A record of each case must be made upon the card provided 
for the purpose, to be kept by the rinpcipal, and upon the large blank 
to be returned to the Board of Health at the end of each week. In case 
any of the above mentioned diseases be found, the Board of Health is 
to be at once notified on blanks provided for this purpose. 

In many cases of exclusion, children should be allowed to return to 
school promptly if they can furnish evidence that they are under treat- 
ment for the disease indicated. In this way many children suffering 
from ailments of a special nature will be permitted to attend school 
instead of being kept out of their classes. 

Swabs should be taken by the Inspector from all suspicious throats. 

Medical Inspectors (or the family physician) are expected to vacci- 
nate such children as require it. No prescription or medical treatment 
is to be given any child by the Medical Inspector while in the perform- 
ance of his duties except as follows: 

In special cases prescriptions, furnished by the Health Department, 
are to be provided free of charge for the following diseases : Impetigo 
contagiosa, ringworm, scabies, animal parasites in the hair. 

Rules governing the admission of children to school after illness 
with contagious disease: 

School children may return to school after — 

Diphtheria when two negative cultures have been obtained. 

Scarlet fever after three weeks, or when peeling has ceased. 

Measles when catarrhal symptoms have ceased. 

Whooping cough after cough has stopped. 

Mumps when swelling has disappeared. , , 

Chickenpox when skin is free from crusts and scabs. 



262 Medical Inspection of Schools 

During the continuance of diphtheria and scarlet fever in the house- 
hold, school children exposed to the contagion cannot retiurn to school. 

The Medical Inspector's attention should be called to any of the 
following conditions: 

Skin and Hair 

A. Animal parasites or nits in the hair. 

B. Crusted or scaly patches or sores about the face, neck, or 

hands, 

C. Crusts in the scalp or loss of hair. 

D. Scaling about the fingers, 

E. Pimples in the spaces between the fingers. 

F. Swollen glands. 

G. Any evidence of pronounced itching on the part of the child. 

Eyes 

A. Sensitiveness to light. 

B. Redness of the eyes, 

C. Discharge from the lids, 

D. Crusted condition about the eyelashes. 

Ears 

Running from the ears and crusty patches thereon. 

Children who are slightly hard of hearing sit with their mouths 
partially open, which gives them a somewhat dull expression. They 
hear questions imperfectly, hence are slow and often stupid in their 
answers, since they try to conceal the hardness of hearing. 



Inde 



X 



Adenoids — 

EiTect on pupils of 15 

Study of, in Philadelphia 189 

Data concerning, in New York 
City ...192, 193, 195, 196, 197, 199 

Aix-la-Chapelle — 

Salaries of school inspectors in. . 144 

Alabama- 
Inquiries regarding medical in- 
spection unanswered in 182 

Albany, N. Y.— 

Medical inspection in 26 

List of symptoms of disease fur- 
nished to teachers in 55 

Albany County Medical Society — 

Medical inspection conducted by 26 

Allen, Dr. William H.— 

Quotation from 16 

Allport, Dr. Frank- 
Quotation from 106 

Instructions prepared by 129 

America — 

Salaries of school physicians in i 

Comprehensive systems rare in.. 82 

American School Hygiene Asso- 
ciation — 
Second Congress of 159 

Ann Arbor, Mich. — 

Medical inspection in 26 

Dr. Elliott Kent Herdman, medi- 
cal inspector of 53 

Card of notification to parents. . 96 

Antwerp — 

Development of medical inspec- 
tion in 19 

Argentine Republic — 

Medical inspection in i 

Scope of medical inspection in.. 23 



Arizona — 

Inquiries regarding medical in- 
spection unanswered 182 

Arkansas — 

Inquiries regarding medical in- 
spection unanswered 182 

Asbury Park, N. J. — 

Medical inspection in 26 

Teacher's request to inspector, 

card 59 

Quotation from Superintendent 

of Schools 154 

Associated Charities — 

Of Minneapolis, Minn 26 

Associated Charities and Wo- 
men's Club — 
Medical inspection conducted by, 
in Minneapolis, Minn 26 

Atlantic City, N. J.— 

Medical inspection in 26 

Congress of American School 
Hygiene Association in 159 

Attendance, Average — 

In seventeen cities 140 

In Springfield, Mass 146 

In Montclair, N. J 146 

Austria — 

Development of medical inspec- 
tion in 20 



Backward Children — 

Study of problems of 14 

Discussion concerning 185, 186 

Investigation concerning, in 

Camden, N. J 190 

Investigation concerning, in New 

York City 192 

Conclusions regarding 201 



263 



264 



Index 



Baltimore, Md. — 

Medical inspection in 26 

School nurses in 67 

Dr. H. W. Buckler, medical in- 
spector in 72 

Weekly report of nurse in 79 

Medical inspection under city 
ordinances 172 

Bannon, Dr. John H. — 

Appointed school physician, 
Lawrence, Mass 155 

Bayonne, N, J. — 

Defective vision in schools of . . .82, 83 

Belgium — 

Medical inspection in i 

Development of medical inspec- 
tion in 19 

Blake, Dr. Clarence J. — 

Opinion signed by 105 

Blauvelt, Dr. A.— 

Appointed Chief Medical Inspec- 
tor in New York City 24 

Boas, Dr. Franz — 

Work of, in Toronto and Wor- 
cester, Mass 6 

Boston — 

Work of Dr. H. P. Bowditch in. . 6 
Population of foreign parentage 

in 7 

First medical inspection in 24 

Children referred to medical in- 
spectors in 53 

School nurses in 67 

Department of School Hygiene in 73 
Facts concerning medical inspec- 
tion in 140 

Salary of nurses in 143 

Extract from report of Superin- 
tendent of Schools of 153 

Medical inspection begun 168 

Bowditch, Dr. H. P.— 

Work of, in Boston 6 

Breathing, Defective — 

Data concerning, among New 
York City children 

192, 193, 19s, 196, 197, 199 

British Board of Education — 
Quotation from Memorandum 

of 1, 21, 168, 184 

Reference to Memorandum of . . 160 



Brockton, Mass. — 

Exclusion card used in 30 

Monthly report of medical in- 
spector 31 

Examinations and exclusions in. 49 
Facts concerning medical inspec- 
tion in 140 

Brussels — 

Development of medical inspec- 
tion in 19 

Bryan, Dr. James E. — 

Investigation conducted by 190 

Buckler, Dr. H. W.— 

Medical inspector of Baltimore. 72 

Buffalo, N. Y.— 

Medical inspection in 26 

Bulgaria — 

Medical inspection in i 

Bureau of Education, United 
States — 
Bulletin of 188 



Cairo, Egypt — 

Salaries of school physicians in. . 23 

California — 

Eyesight and hearing tests by 
State Board of Health 25 

Legal status of medical inspec- 
tion in 176 

Camden, N. J, — 

Medical inspection in 26 

Defective vision in schools of 83 

Facts concerning medical inspec- 
tion in 140 

Reference to school conditions in 188 
Investigation by Superintendent 
of Schools in 190 

Chart— 

Of teeth, used in Northampton, 

Mass 97 

Pray Astigmatic 106 

Snellen in, 129, 130 

For testing vision, Connecticut 
State Board of Education 

122, 123, 124, 125 

Chelsea, Mass. — 

Facts concerning medical inspec- 
tion in 140 



Index 



265 



Chicago — 

Population of foreign parentage 

in 7 

First medical inspection in 24 

System of inspectors' reports in. 41 

Exclusion notice 42 

Envelope report of medical in- 
spector 43 

Number of medical inspectors 

employed in 138 

Medical inspection begun 168 

Legal status of medical inspec- 
tion in 174 

Chicopee, Mass. — 

Results of physical examinations 
in 88 

Children per Inspector — 

In seventeen cities 140 

Chile- 
Development of medical inspec- 
tion in 23 

Cincinnati, O. — 

Medical inspection in 26 

Cleveland, O. — 

Work of George W. Ehler in 6 

Population of foreign parentage 

in 7 

Medical inspection in 26 

Defective vision in schools of 82, 83 

Reference to report of Superin- 
tendent of Schools of 102 

Free eyeglasses in 148 

Extract from report of Superin- 
tendent of Schools 153 

Code Card — 

New York City 36 

Colorado — 

Legal status of medical inspec- 
tion in 176 

Connecticut — 

Medical inspection law i 

Law concerning testing of eye- 
sight 25, 104 

Reference to medical inspection 
law 137 

Legal status of medical inspec- 
tion in 176 

Contagious Diseases — 

Excluded in New York City ^s 



Postal card of notification con- 
cerning 43 

For which pupils are excluded in 

various cities 48 

Rules for, in Providence, R. I. . . 56 

Cornell, Dr. Walter S.— 

Quotations from 66, 76, 102 

Work of, in Philadelphia 77 

Reference to studies by 189 

Cornman, Dr. O. P. — 

Reference to article by 188 

Craps — 

Game of 10 

Cronin, Dr. John J. — 

Work of, in New York City 6 

Quotation from 66 

Opinion of 143 



Dallas, Texas — 

Medical inspection in 26 

Dayton, O. — 

Medical inspection in 26 

Defective Hearing — 

In various school systems 83 

Defective Vision — 

Problem of pupil with 15 

In various school systems 83 

Data concerning in New York 
City . . . 192, 193, 195, 196, 197, 199 

Defects, Physical — 

Decrease with age 2, 199 

Reported in Massachusetts 49 

Not discovered by teachers 81 

Delaware — 

Inquiries regarding medical in- 
spection unanswered 182 

Dental School of Harvard Uni- 
versity — 
New Bedford leaflet endorsed by 98 

Dental School of Tufts College- 
New Bedford leaflet endorsed by 98 

Des Moines, Iowa — 

Medical inspection in 26 

Detroit, Mich. — 

Medical inspection in 26, 179 

Diseases for which pupils are ex- 
cluded in 48 



266 



Index 



Detroit, Mich. — Cont'd. 

System of sending pupils to in- 
spectors in 52 

Facts concerning medical inspec- 
tion in 140 

Diseases — 

Reported in Massachusetts 49 

Dispensary — 

Founded in Havre, France 19 

District of Columbia — 

Legal status of medical inspec- 
tion in 174 

Dresden — 

Development of medical inspec- 
tion in 19 

Dunfermline, Scotland — 

Data on defective teeth of chil- 
dren in. 97 

Defective vision in schools of 83 

Durgin, Dr. Samuel H. — 

Opinion of 50 

E's— 

Direction for using chart of 115 

Chart of 125 

East Sussex, England — 

Cost of medical inspection in 147 

Edinburgh — 

Defective vision in schools of 83 

Edison, Dr. Cyrus — 

Sanitary Superintendent, New 
York City 24 

Egypt- 
Salaries of school physicians in. . 23 

Ehler, George W.— 

Work of, in Cleveland, 6 

Elgin, 111.— 

Medical inspection in 26 

England — 

Medical inspection in i 

Salaries of school physicians in . . i 

Feeding of school children 16 

Society of Medical Ofl&cers for 

Schools 22 

Payment of school physicians ac- 
cording to work done 144 

Medical inspection act 159 



Englewood, N. J. — 

Medical inspection in 26 

Epidemics — 

Closing of public schools during 12 

Evansville, Ind. — 

Medical inspection in 26 

Everett, Mass. — 

Combined directions and pre- 
scriptions 44, 45, 46 

Examinations — 

And exclusions in five cities 49 

Exclusion Card — 

Brockton, Mass 30 

New York City 35 

Chicago 42 

Exclusions — 

Inspector's daily report of. New 

York City 38 

In five cities 49 

In Haverhill, Mass., and Newark, 

N.J 150 

In Massachusetts and in New 

York City 151 

Eyeglasses — 

By whom furnished 147 

Given away in Cleveland, O 148 

Furnished at $1.00 in Lowell, 

Mass 14S 

Furnished at cost price in Phila- 
delphia 148 

Eyesight — 

Problem of pupil with defective. 15 
(See also Vision) 

Eyesight and Hearing Tests — 

Under state boards of health 25 

(See also Vision) 



Falkner, Dr. Roland P.— 

Reference to article by 188 

Florida — 

Legal status of medical inspection 177 

Foreign Parentage — 

Population of, in various Amer- 
ican cities 7 

Fort Dodge, Iowa — 

Medical inspection in 26 



Index 



267 



Fort Worth, Texas- 
Medical inspection in 26 

Fourth Section, Philadelphia — 

Work in schools of 69 

Work of trained nurse in 70 

France — 

Medical inspection in i 

Feeding of school children in 16 

Development of medical inspec- 
tion in i8 

Society of Medical Inspectors of 

Schools 22 

La Medecine Scolaire 22 



Galveston, Texas — 

Medical inspection in 26 

Georgia — 

Legal status of medical inspec- 
tion in 177 

Germany — 

Development of medical inspec- 
tion in 19 

Care of teeth of children in 97 

Salaries of school physicians ac- 
cording to work done 144 

Glands, Enlarged — 

Data concerning, among New 
York City children 

192, 193, 195, 196, 197, 199 

Grand Rapids, Mich. — 

Medical inspection in 26 

Dr. C. Koon of 52 

School nurses in 67 

Greece — 

Golden Age of 8 

Guildford, England — 

Salaries of inspectors in 142 



Hackensack, N. J. — 

Medical inspection in 26 

Half Time- 
Discussion concerning 185, 186 

Conclusions concerning 187, 201 

Harrington, Dr. Thomas F. — 

Quotation from 53, 66, 152 



Harrisburg, Pa. — 

Medical inspection in 26 

Quotation from Report of School 

Nurses 103 

Reference to report to School 

Board of 141 

Hartford, Conn. — 

Medical inspection in 26 

Harvard College, Dental School 
of— 

New Bedford leaflet endorsed by 98 

Haskin, Frederick J. — 

Extract from article by 23 

Haverhill, Mass. — 

Exclusions in 150 

Extract from report of Superin- 
tendent of Schools 156 

Havre, France — 

Free public dispensary 19 

Hazleton, Pa. — 

Medical inspection in 26 

Hearing Tests — 

Time of 2 

In Massachusetts 109 

Report of, in Massachusetts no 

Record of, in Massachusetts 112 

By New York State Department 

of Health 113, 116 

Report of teacher on 1 19 

By State Board of Health, Utah. . 129 
Report on, Utah 131, 132, 133 

Herdman, Dr. Elliott Kent- 
Quotation from 54 

Houston, Texas — 

Medical inspection in 26 

Association of Opticians and 
Aurists 26 

Hungarian — 

Children, statement concerning . 103 

Hungary — 

Development of medical inspec- 
tion in 20 

Hypertrophied Tonsils — 

Effect on pupils of 15 

Data concerning, among New 
York City children 

192, i93> 195. 196, i97> 199 



268 



Index 



Idaho — 

Legal status of medical inspec- 
tion in 177 

Illinois — 

Per cent, of urban population in 6 
Legal status of medical inspec- 
tion in 174 

Index Card — 

New York City 37 

Indiana — 

Legal status of medical inspec- 
tion 176 

Iowa — 

Inquiries regarding medical in- 
spection unanswered 182 

Italian — 

Directions printed in 40, 46 

Japan — 

Medical inspection in i, 23 

Jersey City, N. J.— 

Medical inspection in 26 

Juvenal — 

Quotation from 12 

Kansas — 

Legal status of medical inspec- 
tion in 178 

Kentucky — 

Legal status of medical inspec- 
tion in 178 

Knowles, Dr. William F.— 

Opinion signed by 105 

Koon, Dr. C. — 

Quotation from 52 

Lancet, The — 

Advertisements in 142 

Lansing, Mich, — • 

Medical inspection in 26 

Dr. Burt Nottingham of 52, 53 

Lawrence, Mass. — 

Examinations and exclusions in. 49 
Facts concerning medical inspec- 
tion in 140 

Conflict between Board of Health 
and Board of Education 155 



Laws on Medical Inspection — 

Connecticut i, 25, 104, 137, 176 

English 159 

Massachusetts 

I, 16, 25, 104, 137, 159, 162 

New Jersey i, 16, 25, 171 

New York i66 

Vermont i, 25, 137, 181 

Leaflets — 

On care of teeth, New Bedford, 
Mass 98 

On care of teeth, Waltham, Mass. 99 

Lederle, Dr. Ernest J. — 

Quotation from 66 

Leipsic — 

Development of medical inspec- 
tion in 19 

Salaries of school inspectors in. . 144 

Leslie, Prof. George L. — 

Quotation from 94, 106 

Lice — 

(See Pediculosis) 44 

Liege, Belgium — 

Development of medical inspec- 
tion in 19 

Lincoln, Neb. — 

Medical inspection in 26 

Littleton, Mass. — 

Salary of school physician in 141 

Lockstep — 

In physical matters 13 

In promotions 188 

London — 

Children referred to medical in- 
spectors in 53 

School nurses in 66 

Long Beach, Cal. — 

Medical inspection in 26 

Los Angeles, Cal.— 

Medical inspection in 26 

Superintendent of Schools, E. C. 

Moore, of 52, 53 

School nurses in 67 

Physical examinations in 89, 139 

Louisiana — 

No medical inspection laws in 182 



Index 



269 



Louvain, Belgium — 

Development of medical inspec- 
tion in 19 

Lowell, Mass. — 

Eyeglasses furnished at uniform 
price in 148 



Maddox— 

Multiplex Rod 106 

Maine — 

No medical inspection laws in.. 182 

Mannheim, Germany — 

Salaries of school inspectors in.. 144 

Martin, George H. — 

Quotation from 157 

Maryland — 

Extract from code of public 
health laws in 172 

Massachusetts — 

Medical inspection in i 

Medical inspection law in i, 16, 25 

Extent of medical inspection in 25, 27 

School membership in 49 

Diseases and defects reported in 49 
Pamphlet issued by State Board 

of Education 54 

Defective vision in schools of 83 

Medical Society of 106 

Reference to medical inspection 

law in 104, 159 

Extract from medical inspection 

law in 137 

Exclusions in 151 

Medical inspection law quoted in 

full 162 

Maxwell, Dr. William H.— 

Quotation from 151 

Measles — 

Statistics concerning mortality 
from, in Munich 50 

Medical Academy of Dental 
Science — 

New Bedford leaflet endorsed by 98 

Medical Inspector — 

Monthly report of, Brockton, 

Mass 31 

Teacher's request to, Providence, 

RI 59 



Teacher's request to, Asbury 

Park, N. J 59 

Teacher's request to, Washing- 
ton, D. C 60, 61 

Teacher's request to, Somerville, 

Mass 62 

Number of, in seventeen cities. . 140 

Children per, in seventeen cities. 140 

Salaries of, in seventeen cities 140 

Medical Journal, New York — 

Reference to article in i8g 



Medical Society of Pennsyl- 
vania — 
Paper read before 



69 

Michigan — 

Conference of health ofi&cers in . . 54 
Legal status of medical inspec- 
tion in 178 

Milwaukee, Wis. — 

Population of foreign parentage 

in 7 

Medical inspection in 26 

Medical Society 26 

Defective vision in schools of 83 

Miimeapolis, Minn. — 

Medical inspection in 26, 179 

Associated Charities and Wo- 
men's Club 26 

Defective vision in schools of 83 

Physical examinations in 87 

Minnesota — 

Legal status of medical inspec- 
tion in 179 

Mississippi — 

No medical inspection laws in . . 182 

Missouri — 

No medical inspection laws in.. 182 

Montana — 

No medical inspection laws in . . 182 

Montclair, N. J. — 

Medical inspection in 26 

Examinations and exclusions in. 49 
Facts concerning medical inspec- 
tion in 140 

Cost of medical inspection in. . . 146 

Montgomery County Medical 
Society — 

Medical inspection conducted by 26 



270 



Index 



Monthly Report — 

Of medical inspector, Brockton, 
Mass 31 

Moore, E. C. — 

Reference to 52 

Quotation from 53 

Morse, Dr. Moreau — 

Appointed Medical Inspector of 
Schools, New York City 24 

Moscow — 

Medical inspection in 21 

Mount Holly, N. J.— 

Medical inspection in 26 

Munich — 

Statistics concerning mortality 
from measles in 50 



National Educational Associa- 
tion — 

Extract from address delivered 
before Department of Super- 
intendence of the 53 

Nebraska — 

Legal status of medical inspec- 
tion in 179 

Nevada — 

No medical inspection laws in.. 182 

Newark, N. J. — 

Medical inspection in 26 

Diseases for which pupils are ex- 
cluded in 48 

Examinations and exclusions in. 49 
Facts concerning medical inspec- 
tion in 140 

Exclusions in 150 

Extract from report of Superin- 
tendent of Schools 153 

Statement of Superintendent of 
Schools of 171 

New Bedford, Mass. — 

Leaflet on care of teeth in 98 

New Hampshire — 

Legal status of medical inspection 
in 179 

New Haven, Coim. — 

ri: Medical inspection in 26 

j^ School nurses in 67 



Facts concerning medical inspec- 
tion in 140 

New Jersey — 

Medical inspection law in 

I, 16, 25, 171 

Newmayer, Dr. S. W. — 

Quotation from 58, 66 

Card used by, in Philadelphia.. 63 
Reference to paper by 69 

New Mexico — 

Inquiries regarding medical in- 
spection unanswered 182 

New Orleans, La. — 

Medical inspection in 27 

Newport, R. I. — 

Medical inspection in 26 

Newton, Mass. — 

Quotation from Superintendent 
of Schools loi 

New York City- 
Work of Dr. John J. Cronin in . . 6 
Population of foreign parentage 

in 7 

First medical inspection in 24 

Medical inspection in 27 

Description of system in 30 

Diseases for which pupils are ex- 
cluded in 48 

Salaries of nurses in 66, 143 

Corps of nurses established in . . 67 

Duties of school nurse in 74 

Defective vision in schools of 83 

Physical examinations in 85, 87 

Quotation from Superintendent 

of Schools of 102, 151 

Physical examinations in 139 

Facts concerning medical inspec- 
tion in 140 

Exclusions in 151 

Account of medical inspection in 169 
Physical defects of children in.. 188 

Investigation conducted in 191 

Physical examination by Board 
of Health of 198 

New York State- 
Percent, of urban population in. 6 
Eyesight and hearing tests by 

State Board of Health in 25 

Examinations conducted by De- 
partment of Health in 104 



Index 



271 



New York St&te— Cont'd. 

Law concerning children in insti- 
tutions in 166 

Norristown, Pa. — 

Medical inspection in 27 

Northampton, England — 

Salaries of inspectors in 142 

Northampton, Mass. — 

Teeth chart used in 97 

North Carolina — 

Inquiries regarding medical in- 
spection unanswered 182 

North Cumberland, England — 

Salaries of inspectors in 142 

North Dakota- 
No medical inspection laws in. . . 182 

Norway — 

Development of medical inspec- 



Nose and Throat Defects — 

Data concerning 189 

Nottingham, Dr. Burt — 

Reference to opinion of 52 

Quotation from 53 

Nurses — 

Appointment of, in New York 

City 32 

Work of, in Fourth Section, Phil- 
adelphia 70 

Visits to homes 71 

Work of, in New York City 74 

Weekly report of, Philadelphia. 78 

Weekly report of, Baltimore 79 

Quotation from report of 103 



Ogden, Utah- 
Medical inspection in 27 

Teacher's report to principal in. 133 

Card of warning to parents in 133 

Excuse for absence of pupil in . . 134 

Ohio- 
Percent, of urban population in. 6 
Legal status of medical inspection 



180 



Oklahoma — 

Legal status of medical inspection 



180 



Ophthalmologist — 

In Philadelphia 148 

Orange, N. J. — 

Medical inspection in 27 

School nurses in 67 

Oregon- 
Legal status of medical inspection 
in 180 

Osier, Prof. William- 
Quotation from 141 



Parents — 

Notice to. New York City 86 

Notice to, Somerville, Mass 96 

Notice to, Ann Arbor, Mich 96 

Notice to, Massachusetts 113 

Paris — 

Development of medical inspec- 
tion in 18 

Part Time- 
Discussion concerning 185, 186 

Conclusions concerning 187, 201 

Pasadena, Cal. — 

Medical inspection in 27 

Physical examinations in 89 

Passaic, N. J. — 

Medical inspection in 27 

Paterson, N. J. — 

Medical inspection in 27 

Facts concerning medical inspec- 
tion in 140 

Pawtucket, R. I.— 

Defective vision in schools of 83 

Pediculosis — 

Directions for, Everett, Mass.. .44, 45 
Mention of card concerning, 

Utica, N. Y 46 

Pupils excluded for, in five cities 48 
Pupils excluded for, in New York 

City 69,74 

Proportion of exclusions for 151 

Pennsylvania — 

Hospitals 76 

No medical inspection legislation 
in 173 

Per Capita Cost — 

Of medical inspection in America i 



272 



Index 



Per Capita Cost — Cont'd. 

Of inspection for detection of con- 
tagious diseases 2 

Of physical examinations 2 

For salaries in seventeen cities . . 140 

In twenty-four cities 141 

Pericles — 

The Age of 8 

Philadelphia — 

Resolution of Bureau of Health 

of 24 

Medical inspection in 27 

Diseases for which pupils are ex- 
cluded in. 48 

Dr. Newmayer of 58 

Card used by Dr. Newmayer 63 

School nurses in 67 

Report of work of nurses in 

schools of Fourth Section of . . 70 

Visits of nurse to homes in 71 

Card recommending pupil for 

treatment in 77 

Weekly report of nurse in 78 

City ophthalmologist of 148 

Medical inspection begun in 168 

Legal status of medical inspec- 
tion in 173 

Physical Defects — 

Decrease with age 2, 199 

Per cent, attended to by parents. 10 1 

Physical Examinations — 

Per capita cost of 2 

In New York City 85 

In Minneapolis and in New York 

City _. 87 

In Sioux City, Iowa 88 

In Chicopee, Mass 88 

In Los Angeles, Cal 89 

In Pasadena, Cal 89 

Physical Record Cards — 

Pasadena, Cal 90 

Los Angeles, Cal 92 

Utica, N. Y 94 

Asbury Park, N.J 95 

Pinard, Prof. — 

Use of term " puericulture " by. . 22 

Plainfield, N. J.— 

Medical inspection in 27 

Play- 
Changed conditions of 9 



Polk County Medical Associa- 
tion — 

Medical inspection conducted by 26 

Port Chester, N. Y.— 

Medical inspection in 27 

Porter, Dr. Eugene H. — 

New York State Board of Health 
instructions signed by 117 

Porter, Dr. William H.— 

Work of, in St. Louis, Mo 6 

Portland, Oregon — 

Medical inspection in - -27, 180 

Pray — 

Astigmatic Charts 106 

Providence, R. I. — 

Medical inspection in 27 

Printed material used in 40 

Rules for contagious diseases in. 56 

Rules distributed to pupils in 57 

Teacher's request to inspector.. 59 

Psychological Clinic — 

Reference to publication of 188 

Reference to article in 189 

Reading, Pa. — 

Medical inspection in 27 

Rebuck, Dr. C. S.— 

Medical inspection by, in Harris- 
burg, Pa 26 

Record Cards — 

Individual, New York City 84 

Giving teacher's comment, Pasa- 
dena, Cal 90 

Physical, Los Angeles, Cal 92, 93 

Physical, Utica, N. Y 94 

Physical, Asbury Park, N. J. 95 

Sight and hearing tests, Massa- 
chusetts 112 

Reports — 

Monthly, of medical inspector, 

Brockton, Mass 31 

Inspector's daily, of exclusions, 

New York City 38, 39 

Envelope, daily, Chicago, 111. — 43 
Weekly, of nurse, Philadelphia, 

Pa 78 

Weekly, of nurse, Baltimore, Md. 79 
Of sight and hearing, Massa- 
chusetts 1 10 



Index 



273 



Reports — Cont'd. 

Of teacher, New York State. . 1 18, 1 19 

Of teacher, Connecticut 127, 128 

To State Board of Health, Utah 132 
Of teacher to principal, Ogden, 
Utah 133 

Retarded Children- 
Study of problems of 14 

Discussion concerning 185, 186 

Investigation concerning, Cam- 
den, N. J 190 

Investigation concerning, New 

York City 192 

Conclusions regarding 201 

Rhode Island — 

Per cent, of urban population in. 6 
Legal status of medical inspec- 
tion in ^^^ 

Rochester, N. Y.— 

Medical inspection in 



Opinion of Deputy Superinten- 
dent of Schools 176 



27 



Schamberg, Dr. — 
Reference to 



Roumania — 

Development of medical inspec- 
tion in 21 



Salaries — 

Of school physicians in America 
and in England i 

Of medical inspectors in Cairo, 
Egypt ; 23 

Of medical inspectors m seven- 
teen cities 140 

Of school physicians in Shelburne 
and Littleton, Mass 141 

Of medical inspectors in England 142 

Of school nurses in New York 
and Boston i43 

Of school nurses in New Haven, 
Conn 144 

Of medical inspectors in Wies- 
baden, Germany - - i44 

Of medical inspectors in Leipsic, 
Aix-la-Chapelle, and Mann- 
heim, Germany I44 

Salt Lake City, Utah- 
Medical inspection in 27 

San Antonio, Texas- 
Medical inspection in 27 

San Francisco, Cal. — 

Population of foreign parentage 

in 7 

18 



76 

Schenectady, N. Y.— - 

Medical inspection in 27 

School Hygiene, Department 
of— 
Boston 73 

Schubert, Dr. Paul- 
Quotation from 



144 

Seattle, Wash.— 

Medical inspection in 27 

Facts concerning medical inspec- 
tion in 140 

Shelburne, Mass. — 

Salary of school physician in. 

Shepherd, Dr. Fred S.— 
Quotations from 

Sioux City, Iowa- 
Medical inspection in . . 

Physical examinations in 



141 



154 



27 



Snellen — 

Test types 106 

Chart I" 

Directions for using chart .. .129, 130 

Society— ^ , , 

Of Medical OflScers for Schools . . 22 

Of Medical Inspectors of Schools 22 

Medical, of Pennsylvania 69 

Visiting Nurse, of Philadelphia . . 69 

Medical, of Massachusetts 106 

Somerville, Mass. — 

Card of statement of physician 
and teacher in - - 62 

Card of notification"of parents in 96 

Quotation from Superintendent 
of Schools of ; loi 

Facts concerning medical inspec- 
tion in 140 

South Carolina — 

Legal status of medical inspec- 
tion in ^°^ 

South Dakota — 

No medical inspection laws m . . . 182 

Springfield, Mass. — 

Examinations and exclusions m. 49 



274 



Index 



Springfield, Mass. — Cont'd. 

Facts concerning medical inspec- 
tion in 140 

Cost of medical inspection in . . . 146 
Quotation from report of School 
Board of 156 

Standish, Dr. Myles — 

Opinion of 105 

Stanley, Annie L. — 

Work of, in Philadelphia 69 

Stewart, Dr. Hackworth — 

Quotation from 161 

St. John, Dr. S. B.— 

Instructions prepared by 121 

St. Joseph, Mo. — 

Medical inspection in 27 

St. Louis, Mo. — 

Work of Dr. William H. Porter in 6 
Medical inspection in 27 

Suffolk County, Mass.— 

Defective vision in schools of — 83 

Superior, Wis. — 

Medical inspection in 27 

Sweden — 

Medical inspection in i 

Development of medical inspec- 
tion in 21 

Switzerland — 

Medical inspection in i 

Development of medical inspec- 
tion in 21 

Syracuse, N. Y. — 

Medical inspection in 27 

Description of record card used in 46 

Directions furnished teachers in. 56 

School nurses in 67 



Teeth- 
Chart used in Northampton, 

Mass 97 

Care of, in Germany 97 

Data from Dunfermline, Scot- 
land 97 

Leaflet on care of. New Bedford, 

Mass 98 

Leaflet on care of, Waltham, 
Mass 99 



Defective, data concerning, 
among New York City chil- 
dren ...192, 193, 195, 196, 197, 199 

Tennessee — 

Inquiries regarding medical in- 
spection unanswered 182 

Texas — 

Legal status of medical inspec- 
tion in 181 

Thorndike, Dr. Edward L.— 

Reference to publication of 188 

Time— 

Of vision and hearing tests 2 

Of physical examinations 2 

Of examinations as basis for re- 
muneration 143 

Tonsils — 

Enlarged, effect on pupils 15 

Enlarged, study of, in Phila- 
delphia 189 

Enlarged, data concerning, 
among New York City chil- 
dren... 192, 193, 195, 196, 197, 199 

Toronto — 

Work of Dr. Franz Boas in 6 

Tufts College, Dental School of— 

New Bedford leaflet endorsed by 98 



Union Hill, N. J.— 

Medical inspection in 27 

United States — 

First medical inspection in 24 

Cities of, having medical inspec- 
tion 26 

Urban Population — 

Change in 6 

Percentage of, in various states . . 6 

Utah- 
Eyesight and hearing tests under 

State Board of Health of 25 

Examinations conducted by State 

Board of Health of 104 

Legal status of medical inspec- 
tion in 181 

Utica, W. Y.— 

Description of record card used 
in 46 

Defective vision in schools of 83 



Index 



275 



Vandiver, Almuth C. — 

Reference to paper by 159 

Vermont — 

Medical inspection law in i 

Reference to medical inspection 

law 25,137 

Legal status of medical inspec- 
tion in 181 

Virginia — 

Inquiries regarding medical in- 
spection unanswered 182 

Vision and Hearing Tests — 

Time of 2 

By school teachers, opinions con- 
cerning 105 

In Massachusetts 107 

Report of no, 118, 127, 132, 133 

Snellen's chart for in 

Record of 112 

By New York State Department 

of Health 113 

By State Board of Education, 

Connecticut 120 

Charts used in 122, 123, 124, 125 

By State Board of Health, Utah 129 

Vision, Defective — 

In various school systems 83 

Data concerning, in New York 
City.... 192, 193, 195, 196, 197, 199 

Visiting Nurse Association — 

Of Harrisburg, Pa 26 

Visiting Nurses' Society — 

Of Philadelphia 69 



Wadsworth, Dr. O. F.— 

Opinion of 106 

Walker, Dr. D. Harold- 
Opinion signed by 105 

Waltham, Mass. — 

Diseases for which pupils are ex- 
cluded 48 

Attention to children's teeth in. . 98 
Leaflet on care of teeth 99 

Washington, D. C— 

Medical inspection in 27 

Meeting of Department, National 
Educational Association in 53 



Teacher's request to inspector. 60, 6i 

Washington State — 

Legal status of medical inspec- 
tion in 182 

Waterbury, Conn. — 

Medical inspection in 27 

Waverly, R. I.— 

Medical inspection in 27 

Webster, R. H.— 

Opinion of 176 

Wells, Dr. David W.— 

Quotation from 106 

Westchester, N. Y.— 

Medical inspection in 27 

West Riding District, England — 
Salaries of inspectors in 142 

West Virginia — 

Inquiries regarding medical in- 
spection 182 

White Plains, N. Y.— 

Medical inspection in 27 

Directions furnished teachers in. 56 

Wiesbaden, Germany — 

Method of medical inspection 19 

Salaries of school inspectors in. . 144 

Wilkes-Barre, Pa,— 

Printed rules distributed to pupils 57 

Williams, Dr. Charles H.— 

Opinion of 106 

Wilmington, Del. — 

Medical inspection in 27 

Reference to study of school con- 
ditions in 188 

Wisconsin — 

Legal status of medical inspection 
in 182 

Witmer, Dr. Lightner — 

Founder of Psychological Clinic. 188 

Women's Club — 

Of Minneapolis, Minn 26 

Woonsocket, R. I, — 

Medical inspection in 27 



276 



Index 



Woonsocket, R. I. — Cont'd. 
Facts concerning medical inspec- 
tion in 140 

Worcester, Mass. — 

Work of Dr. Franz Boas in 6 

Defective vision in schools of 83 

Facts concerning medical inspec- 
tion in 140 



Wyoming — 

Inquiries regarding medical in- 
spection unanswered 182 

Yiddish- 
Directions printed in 40 

Yonkers, N. Y.— 

School nurses in 67 



